ID

2046

Description

E2906 Abbreviated Comprehensive Geriatric Assessment Battery Clofarabine or Daunorubicin Hydrochloride and Cytarabine Followed By Decitabine or Observation in Treating Older Patients With Newly Diagnosed Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7586A704-3044-A522-E040-BB89AD4359F8

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7586A704-3044-A522-E040-BB89AD4359F8

Keywords

  1. 9/19/12 9/19/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 1/8/15 1/8/15 - Martin Dugas
  4. 6/8/15 6/8/15 -
  5. 9/20/21 9/20/21 -
Uploaded on

September 19, 2012

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Leukemia NCT01041703 Quality of Life - E2906 Abbreviated Comprehensive Geriatric Assessment Battery - 2952067v1.0

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

Unnamed1
Description

Unnamed1

DCI Name
Description

CollectedDataFormName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus ObjectClass
C25452
Registration Step (Place ID Label Here)
Description

RegistrationStepNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25646
UMLS 2011AA ObjectClass
C1514821
NCI Thesaurus Property
C16154
UMLS 2011AA Property
C1704379
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Patient Initials (Last, First)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
ECOG Protocol Number
Description

ProtocolECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
ECOG Protocol Number
Description

ProtocolECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
ECOG Patient ID
Description

PatientECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
ECOG Patient ID
Description

PatientECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
Participating Group Protocol Number
Description

ProtocolParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participating Group Patient ID
Description

PatientParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution/Affiliate
Description

CombinedInstitutionName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS 2011AA ObjectClass
C0205195
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
On Treatment
Description

On Treatment

On Treatment Report Period (Choose one)
Description

TreatmentEvaluationPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C15368
Unnamed2
Description

Unnamed2

Please mark an 'X' if data have been amended. (Please circle amended items in red)
Description

DataAmendedText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Date data amended (s M D Y)
Description

DataAmendedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
NCI Thesaurus ValueDomain
C25367
Unnamed1
Description

Unnamed1

Date of Assessment
Description

AssessmentPerformedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25367
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
Mini Mental Examination Section
Description

Mini Mental Examination Section

Total Score (ATTENTION AND CALCULATION 1 point for each correct answer Serial 7's: Have patient begin with 100 and count backward by 7. Stop after 5 answers. 1 point for each one correct. Or alternatively: spell 'world' backwards. Score by number of letters in correct order. LANGUAGE 1 point for each correct answer Show the patient the statement "Close your eyes" and have - him read and obey what it says. Have the patient write a sentence with a subject and verb. Have the patient copy the figure)
Description

Mini-MentalStatusExamAdministeredTotalCount

Data type

double

Alias
NCI Thesaurus ValueDomain
C25304
UMLS 2011AA ValueDomain
C0439810
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ObjectClass
C74982
UMLS 2011AA ObjectClass
C1697972
Gds
Description

Gds

Do you feel that your life is empty
Description

PatientAnhedoniaAssessmentInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C3673
UMLS 2011AA Property
C0178417
Do you feel happy most of the time
Description

PatientHappinessAssessmentInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0018592
Do you often feel helpless
Description

PatientHopelessnessAssessmentInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C74531
UMLS 2011AA Property
C0150041
Do you feel pretty worthless the way you are now
Description

PatientWorthlessnessAssessmentInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C74535
UMLS 2011AA Property
C1821293
Adl
Description

Adl

Bathing (sponge bath, tub bath or shower)
Description

BathingPatientAssistanceAssessmentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0150141
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Transfer
Description

TransferPatientAssistanceAssessmentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C48167
UMLS 2011AA ObjectClass
C1705822
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Continence
Description

IncontinencePatientAssistanceAssessmentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0021167
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Can you go shopping for groceries
Description

ShoppingPatientAssistanceAssessmentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C81006
UMLS 2011AA ObjectClass
C0150768
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Can you prepare your own meals
Description

FoodPreparationPatientAssistanceAssessmentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C17604
UMLS 2011AA ObjectClass
C0920297
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Can you do your own housework
Description

HouseholdActivityPatientAssistanceAssessmentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C53291
UMLS 2011AA ObjectClass
C1708387
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Can you do your own laundry
Description

WashPatientAssistanceAssessmentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C65077
UMLS 2011AA ObjectClass
C0441648
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Section Ii - Social Support
Description

Section Ii - Social Support

Someone you can count on to listen to you when you need to talk
Description

QualityofLifePersonDiscussionAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C71323
UMLS 2011AA Property
C2584313
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone whose advice you really want
Description

QualityofLifePersonAdvisingAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C60731
UMLS 2011AA Property
C1828381
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone whose advice you really want
Description

QualityofLifePersonAdvisingAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C60731
UMLS 2011AA Property
C1828381
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone to share your most private worries and fears with
Description

QualityofLifePersonConfidenceAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C43367
UMLS 2011AA Property
C1704726
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone to share your most private worries and fears with
Description

QualityofLifePersonConfidenceAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C43367
UMLS 2011AA Property
C1704726
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone to turn to for suggestions about how to deal with a personal problem
Description

QualityofLifePersonInformationAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C48191
UMLS 2011AA Property
C1533716
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone to turn to for suggestions about how to deal with a personal problem
Description

QualityofLifePersonInformationAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C48191
UMLS 2011AA Property
C1533716
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone who understands your problems
Description

QualityofLifePersonProblemAppreciationAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C72889
UMLS 2011AA Property
C2346843
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Section Ii - Social Support
Description

Section Ii - Social Support

Someone to help you if you were confined to bed
Description

QualityofLifePersonBedRestAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C45985
UMLS 2011AA Property
C0004910
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone to take you to the doctor if you needed it
Description

QualityofLifePersonPhysicianOfficeDeliveryAssessment

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C61560
NCI Thesaurus Property
C16988
UMLS 2011AA Property
C0031834
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone to prepare your meals if you were unable to do it yourself
Description

QualityofLifePersonFoodPreparationAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C62695
UMLS 2011AA Property
C0016452
NCI Thesaurus Property
C25625
UMLS 2011AA Property
C1521827
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Someone to help with daily chores if you were sick
Description

QualityofLifeHouseholdActivitySupportAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C37902
UMLS 2011AA Property
C1521721
NCI Thesaurus Property
C53291
UMLS 2011AA Property
C1708387
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Comorbidity Questionnaire
Description

Comorbidity Questionnaire

Have you ever had a heart attack
Description

PatientPriorMyocardialInfarctionInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C27996
UMLS 2011AA Property
C0027051
NCI Thesaurus Property
C25629
UMLS 2011AA Property
C0332152
Have you ever been treated for heart failure (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
Description

CongestiveHeartFailureHistoryInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C3080
UMLS 2011AA ObjectClass
C0018802
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
Do you have other heart disease
Description

HeartInvolvedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C12727
UMLS 2011AA ObjectClass
C0018787
NCI Thesaurus Property
C25547
Have you had an operation to unclog or bypass arteries in your legs
Description

OtherPeripheralArteryDiseasePresentInd-3

Data type

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C12372
UMLS 2011AA ObjectClass
C0003842
NCI Thesaurus ObjectClass
C25233
UMLS 2011AA ObjectClass
C0205100
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)
Description

PatientTransientIschemicAttackCerebrovascularAccidentPersonalMedicalHistoryInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C29867
UMLS 2011AA ObjectClass
C0679646
NCI Thesaurus Property
C50781
UMLS 2011AA Property
C0007787
NCI Thesaurus Property
C3390
UMLS 2011AA Property
C0038454
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident (If yes)
Description

PatientCerebrovascularAccidentMovementDifficultyPresentInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus Property
C3390
UMLS 2011AA Property
C0038454
NCI Thesaurus Property
C37994
UMLS 2011AA Property
C0026649
NCI Thesaurus Property
C62189
UMLS 2011AA Property
C1299586
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Do you have asthma
Description

AsthmaHistoryInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ObjectClass
C28397
UMLS 2011AA ObjectClass
C0004096
Do you take medicines for your asthma (If yes check one box)
Description

AsthmaMedicationPersonalMedicalHistoryIndicator

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C459
UMLS 2011AA Property
C0013227
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ObjectClass
C28397
UMLS 2011AA ObjectClass
C0004096
Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease
Description

DiseaseEmphysemaBronchitisPresentInd-3

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus Property
C2911
UMLS 2011AA Property
C0006277
NCI Thesaurus Property
C3348
UMLS 2011AA Property
C0034067
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Do you take medicines for your lung disease (If yes check one box)
Description

TherapeuticProcedureDiseaseEmphysemaBronchitisPresentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C49236
UMLS 2011AA ObjectClass
C0087111
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus Property
C2911
UMLS 2011AA Property
C0006277
NCI Thesaurus Property
C3348
UMLS 2011AA Property
C0034067
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Comorbidity Questionnaire1
Description

Comorbidity Questionnaire1

Do you have stomach ulcers, or peptic ulcer disease
Description

DiseaseStomachPresentInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus Property
C12391
UMLS 2011AA Property
C0038351
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
Do you have diabetes (high blood sugar)
Description

DiabetesMellitusDiseasesandDisordersMedicationBaselineUseInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C2985
UMLS 2011AA ObjectClass
C0011849
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus Property
C25213
UMLS 2011AA Property
C1442488
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
How is it treated (If yes check one box)
Description

DiabetesMellitusCurrentTherapeuticProcedureType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus ObjectClass
C2985
UMLS 2011AA ObjectClass
C0011849
NCI Thesaurus Property
C49236
UMLS 2011AA Property
C0087111
Has the diabetes caused any of the following problems (If yes)
Description

PatientDiabetesOrganComplicationPersonalMedicalHistoryType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C2985
UMLS 2011AA Property
C0011849
NCI Thesaurus Property
C2959
UMLS 2011AA Property
C0009566
NCI Thesaurus Property
C13018
UMLS 2011AA Property
C0178784
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Have you ever had the following problems with your kidneys
Description

KidneyDiseasePresentType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C12415
UMLS 2011AA ObjectClass
C0022646
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
Do you have arthritis
Description

PatientArthritisPersonalMedicalHistoryInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C2883
UMLS 2011AA Property
C0003864
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
Do you take medications for it regularly (If yes)
Description

ConcomitantMedicationUseInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass
C25730
UMLS 2011AA ObjectClass
C0521115
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
Do you have any of the following conditions
Description

ConcomitantDiseasePersonalMedicalHistoryType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C25730
UMLS 2011AA ObjectClass
C0521115
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
How often do you see your dentist
Description

PersonDentistVisitType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C52654
UMLS 2011AA Property
C0011441
NCI Thesaurus Property
C25716
UMLS 2011AA Property
C0545082
Please list any other health problems you have in the space below
Description

ChronicDiseaseDiagnosisSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C14141
UMLS 2011AA ObjectClass
C0205191
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C17649
UMLS 2011AA ValueDomain
C0205394
Medications/sexual Function
Description

Medications/sexual Function

On average, how many prescription medicines do you take each day
Description

ConcomitantPrescriptionMedicationUseNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass
C28180
UMLS 2011AA ObjectClass
C1521941
NCI Thesaurus ObjectClass
C25730
UMLS 2011AA ObjectClass
C0521115
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
On average, how many non-prescription medicines (over-the-counter) do you take each day
Description

ConcomitantMedicationUseNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus ObjectClass
C25730
UMLS 2011AA ObjectClass
C0521115
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
During the last 4 weeks, did you have sexual intercourse
Description

SexBehaviorQualityofLifeSexualIntercourseOccurrenceAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C17127
UMLS 2011AA ObjectClass
C0036864
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property
C72881
UMLS 2011AA Property
C0009253
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the past 4 weeks, how would you rate your level of sexual desire
Description

SexBehaviorQualityofLifeOverallSatisfactionAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C17127
UMLS 2011AA ObjectClass
C0036864
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C62185
UMLS 2011AA Property
C0242428
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Weight
Description

Weight

What is your usual weight
Description

PatientNormalWeightMeasurement

Data type

double

Measurement units
  • Kg
Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C14165
UMLS 2011AA Property
C0205307
NCI Thesaurus Property
C25208
UMLS 2011AA Property
C0043100
Kg
How much weight have you lost in the past 6 months
Description

PatientWeightLossMeasurement

Data type

double

Measurement units
  • Kg
Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3445
UMLS 2011AA Property
C0043096
Kg

Similar models

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
CollectedDataFormName
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus ObjectClass)
RegistrationStepNumber
Item
Registration Step (Place ID Label Here)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25646 (NCI Thesaurus ObjectClass)
C1514821 (UMLS 2011AA ObjectClass)
C16154 (NCI Thesaurus Property)
C1704379 (UMLS 2011AA Property)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
PatientInitialsName
Item
Patient Initials (Last, First)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
PatientECOGIdentifierNumber
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
PatientECOGIdentifierNumber
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
ProtocolParticipatingIdentifierNumber
Item
Participating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientParticipatingIdentifierNumber
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CombinedInstitutionName
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
Item Group
On Treatment
Item
On Treatment Report Period (Choose one)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
Code List
On Treatment Report Period (Choose one)
CL Item
Baseline Step 1 (Baseline Step 1)
Item Group
Unnamed2
DataAmendedText
Item
Please mark an 'X' if data have been amended. (Please circle amended items in red)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
DataAmendedDate
Item
Date data amended (s M D Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
Item Group
Unnamed1
AssessmentPerformedDate
Item
Date of Assessment
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
Item Group
Mini Mental Examination Section
Mini-MentalStatusExamAdministeredTotalCount
Item
Total Score (ATTENTION AND CALCULATION 1 point for each correct answer Serial 7's: Have patient begin with 100 and count backward by 7. Stop after 5 answers. 1 point for each one correct. Or alternatively: spell 'world' backwards. Score by number of letters in correct order. LANGUAGE 1 point for each correct answer Show the patient the statement "Close your eyes" and have - him read and obey what it says. Have the patient write a sentence with a subject and verb. Have the patient copy the figure)
double
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C74982 (NCI Thesaurus ObjectClass)
C1697972 (UMLS 2011AA ObjectClass)
Item Group
Gds
Item
Do you feel that your life is empty
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C3673 (NCI Thesaurus Property)
C0178417 (UMLS 2011AA Property)
Code List
Do you feel that your life is empty
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you feel happy most of the time
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0018592 (NCI Metathesaurus Property)
Code List
Do you feel happy most of the time
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you often feel helpless
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C74531 (NCI Thesaurus Property)
C0150041 (UMLS 2011AA Property)
Code List
Do you often feel helpless
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you feel pretty worthless the way you are now
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C74535 (NCI Thesaurus Property)
C1821293 (UMLS 2011AA Property)
Code List
Do you feel pretty worthless the way you are now
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Adl
Item
Bathing (sponge bath, tub bath or shower)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0150141 (NCI Metathesaurus ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Bathing (sponge bath, tub bath or shower)
CL Item
I Receive No Assistance (I receive no assistance)
CL Item
I Receive Assistance In Bathing Only One Part Of The Body (I receive assistance in bathing only one part of the body)
CL Item
I Receive Assistance In Bathing More Than One Part Of The Body (I receive assistance in bathing more than one part of the body)
Item
Transfer
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48167 (NCI Thesaurus ObjectClass)
C1705822 (UMLS 2011AA ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Transfer
CL Item
I Am Able To Move Into And Out Of Bed As Well As Into And Out Of Chair Without Assistance (I am able to move into and out of bed as well as into and out of chair without assistance)
CL Item
I Am Able To Move Into And Out Of Bed Or Chair With Assistance (I am able to move into and out of bed or chair with assistance)
CL Item
I Am Not Able To Get Out Of Bed (I am not able to get out of bed)
Item
Continence
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0021167 (NCI Metathesaurus ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Continence
CL Item
I Am Able To Control Urination And Bowel Movement Completely By Myself (I am able to control urination and bowel movement completely by myself)
CL Item
I Have Occasional Accidents (I have occasional accidents)
CL Item
I Need Someone To Help Me Keep Control Of Urination Or Bowel Movement Or A Catheter Is Used Or I Am Unable To Hold My Urine Or Bowel Movements (I need someone to help me keep control of urination or bowel movement OR a catheter is used OR I am unable to hold my urine or bowel movements)
Item
Can you go shopping for groceries
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C81006 (NCI Thesaurus ObjectClass)
C0150768 (UMLS 2011AA ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Can you go shopping for groceries
CL Item
Without Help (Without help)
CL Item
With Some Help (With some help)
CL Item
I Am Completely Unable To Do Any Shopping (I am completely unable to do any shopping)
Item
Can you prepare your own meals
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17604 (NCI Thesaurus ObjectClass)
C0920297 (UMLS 2011AA ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Can you prepare your own meals
CL Item
Without Help (Without help)
CL Item
With Some Help (With some help)
CL Item
I Am Completely Unable To Prepare Any Meals (I am completely unable to prepare any meals)
Item
Can you do your own housework
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C53291 (NCI Thesaurus ObjectClass)
C1708387 (UMLS 2011AA ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Can you do your own housework
CL Item
Without Help (Without help)
CL Item
With Help (With help)
CL Item
I Am Completely Unable To Do Any Housework (I am completely unable to do any housework)
Item
Can you do your own laundry
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C65077 (NCI Thesaurus ObjectClass)
C0441648 (UMLS 2011AA ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Can you do your own laundry
CL Item
Without Help (Without help)
CL Item
With Help (With help)
CL Item
I Am Completely Unable To Do Any Laundry At All (I am completely unable to do any laundry at all)
Item
Someone you can count on to listen to you when you need to talk
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C71323 (NCI Thesaurus Property)
C2584313 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone you can count on to listen to you when you need to talk
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone whose advice you really want
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C60731 (NCI Thesaurus Property)
C1828381 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone whose advice you really want
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone whose advice you really want
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C60731 (NCI Thesaurus Property)
C1828381 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone whose advice you really want
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to share your most private worries and fears with
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C43367 (NCI Thesaurus Property)
C1704726 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to share your most private worries and fears with
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to share your most private worries and fears with
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C43367 (NCI Thesaurus Property)
C1704726 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to share your most private worries and fears with
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to turn to for suggestions about how to deal with a personal problem
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C48191 (NCI Thesaurus Property)
C1533716 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to turn to for suggestions about how to deal with a personal problem
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to turn to for suggestions about how to deal with a personal problem
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C48191 (NCI Thesaurus Property)
C1533716 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to turn to for suggestions about how to deal with a personal problem
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone who understands your problems
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C72889 (NCI Thesaurus Property)
C2346843 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone who understands your problems
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item Group
Section Ii - Social Support
Item
Someone to help you if you were confined to bed
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C45985 (NCI Thesaurus Property)
C0004910 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to help you if you were confined to bed
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to take you to the doctor if you needed it
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C61560 (NCI Thesaurus Property)
C16988 (NCI Thesaurus Property)
C0031834 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to take you to the doctor if you needed it
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to prepare your meals if you were unable to do it yourself
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C62695 (NCI Thesaurus Property)
C0016452 (UMLS 2011AA Property)
C25625 (NCI Thesaurus Property)
C1521827 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to prepare your meals if you were unable to do it yourself
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to help with daily chores if you were sick
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C37902 (NCI Thesaurus Property)
C1521721 (UMLS 2011AA Property)
C53291 (NCI Thesaurus Property)
C1708387 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to help with daily chores if you were sick
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item Group
Comorbidity Questionnaire
Item
Have you ever had a heart attack
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27996 (NCI Thesaurus Property)
C0027051 (UMLS 2011AA Property)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
Code List
Have you ever had a heart attack
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Have you ever been treated for heart failure (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C3080 (NCI Thesaurus ObjectClass)
C0018802 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
Code List
Have you ever been treated for heart failure (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you have other heart disease
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12727 (NCI Thesaurus ObjectClass)
C0018787 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)
Code List
Do you have other heart disease
CL Item
No (NO)
CL Item
Yes (YES)
Item
Have you had an operation to unclog or bypass arteries in your legs
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C12372 (NCI Thesaurus ObjectClass)
C0003842 (UMLS 2011AA ObjectClass)
C25233 (NCI Thesaurus ObjectClass)
C0205100 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Code List
Have you had an operation to unclog or bypass arteries in your legs
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)
text
C29867 (NCI Thesaurus ObjectClass)
C0679646 (UMLS 2011AA ObjectClass)
C50781 (NCI Thesaurus Property)
C0007787 (UMLS 2011AA Property)
C3390 (NCI Thesaurus Property)
C0038454 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident (If yes)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C3390 (NCI Thesaurus Property)
C0038454 (UMLS 2011AA Property)
C37994 (NCI Thesaurus Property)
C0026649 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
Do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident (If yes)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you have asthma
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C28397 (NCI Thesaurus ObjectClass)
C0004096 (UMLS 2011AA ObjectClass)
Code List
Do you have asthma
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you take medicines for your asthma (If yes check one box)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus Property)
C0013227 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C28397 (NCI Thesaurus ObjectClass)
C0004096 (UMLS 2011AA ObjectClass)
Code List
Do you take medicines for your asthma (If yes check one box)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Only With Flare-ups Of My Asthma (Yes, only with flare-ups of my asthma)
CL Item
Yes, I Take Medicines Regularly Even When I'm Not Having A Flare-up (Yes, I take medicines regularly even when I'm not having a flare-up)
Item
Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2911 (NCI Thesaurus Property)
C0006277 (UMLS 2011AA Property)
C3348 (NCI Thesaurus Property)
C0034067 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Code List
Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you take medicines for your lung disease (If yes check one box)
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C49236 (NCI Thesaurus ObjectClass)
C0087111 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2911 (NCI Thesaurus Property)
C0006277 (UMLS 2011AA Property)
C3348 (NCI Thesaurus Property)
C0034067 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Do you take medicines for your lung disease (If yes check one box)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Only With Flare-ups Of My Lung Disease (Yes, only with flare-ups of my lung disease)
CL Item
Yes, I Take Medicines Regularly Even When I'm Not Having A Flare-up (Yes, I take medicines regularly even when I'm not having a flare-up)
Item Group
Comorbidity Questionnaire1
Item
Do you have stomach ulcers, or peptic ulcer disease
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12391 (NCI Thesaurus Property)
C0038351 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
Code List
Do you have stomach ulcers, or peptic ulcer disease
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you have diabetes (high blood sugar)
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C2985 (NCI Thesaurus ObjectClass)
C0011849 (UMLS 2011AA ObjectClass)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25213 (NCI Thesaurus Property)
C1442488 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
Do you have diabetes (high blood sugar)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How is it treated (If yes check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2985 (NCI Thesaurus ObjectClass)
C0011849 (UMLS 2011AA ObjectClass)
C49236 (NCI Thesaurus Property)
C0087111 (UMLS 2011AA Property)
Code List
How is it treated (If yes check one box)
CL Item
Treated By Modifying My Diet (Treated by modifying my diet)
CL Item
Treated By Medications Taken By Mouth (Treated by medications taken by mouth)
CL Item
Treated By Insulin Injections (Treated by insulin injections)
Item
Has the diabetes caused any of the following problems (If yes)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2985 (NCI Thesaurus Property)
C0011849 (UMLS 2011AA Property)
C2959 (NCI Thesaurus Property)
C0009566 (UMLS 2011AA Property)
C13018 (NCI Thesaurus Property)
C0178784 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Has the diabetes caused any of the following problems (If yes)
CL Item
Problems With Your Kidneys (Problems with your kidneys)
CL Item
Problems With Your Eyes, Treated By An Ophthamologist (Problems with your eyes, treated by an ophthamologist)
CL Item
Problems With Numbness Or Tingling In Your Feet Or Legs (Problems with numbness or tingling in your feet or legs)
Item
Have you ever had the following problems with your kidneys
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12415 (NCI Thesaurus ObjectClass)
C0022646 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
Code List
Have you ever had the following problems with your kidneys
CL Item
Poor Kidney Function (Poor kidney function)
CL Item
Have Used Dialysis (Have used dialysis)
CL Item
Have Received Kidney Transplantation (Have received kidney transplantation)
Item
Do you have arthritis
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2883 (NCI Thesaurus Property)
C0003864 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
Code List
Do you have arthritis
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you take medications for it regularly (If yes)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
Code List
Do you take medications for it regularly (If yes)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Do you have any of the following conditions
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
Code List
Do you have any of the following conditions
CL Item
Alzheimer's Disease, Or Another Form Of Dementia (Alzheimer's Disease, or another form of dementia)
CL Item
Cirrhosis, Hepatitis, Or Serious Liver Disease (Cirrhosis, hepatitis, or serious liver disease)
CL Item
Anemia (Anemia)
C2869 (NCI Thesaurus)
C0002871 (UMLS 2011AA)
CL Item
Depression (Depression)
C2982 (NCI Thesaurus)
C0011570 (UMLS 2011AA)
CL Item
Chronic Sinus Infections (Chronic sinus infections)
CL Item
Chronic Back Pain (Chronic back pain)
CL Item
Osteoporosis (Osteoporosis)
C3298 (NCI Thesaurus)
C0029456 (UMLS 2011AA)
CL Item
Dental Problems (Dental Problems)
CL Item
Cancer (Cancer)
Item
How often do you see your dentist
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C52654 (NCI Thesaurus Property)
C0011441 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property)
C0545082 (UMLS 2011AA Property)
Code List
How often do you see your dentist
CL Item
Every 6-12 Months (Every 6-12 months)
CL Item
Every 1-2 Years (Every 1-2 years)
CL Item
I Don't See A Dentist (I don't see a dentist)
ChronicDiseaseDiagnosisSpecify
Item
Please list any other health problems you have in the space below
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass)
C0205191 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain)
C0205394 (UMLS 2011AA ValueDomain)
Item Group
Medications/sexual Function
Item
On average, how many prescription medicines do you take each day
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C28180 (NCI Thesaurus ObjectClass)
C1521941 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Code List
On average, how many prescription medicines do you take each day
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1-3 (1-3)
CL Item
4-6 (4-6)
CL Item
7-10 (7-10)
CL Item
More Than 10 (More than 10)
Item
On average, how many non-prescription medicines (over-the-counter) do you take each day
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
Code List
On average, how many non-prescription medicines (over-the-counter) do you take each day
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1-3 (1-3)
CL Item
4-6 (4-6)
CL Item
7-10 (7-10)
CL Item
More Than 10 (More than 10)
Item
During the last 4 weeks, did you have sexual intercourse
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C72881 (NCI Thesaurus Property)
C0009253 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
During the last 4 weeks, did you have sexual intercourse
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Once (Yes, once)
CL Item
Yes, More Than Once (Yes, more than once)
Item
Over the past 4 weeks, how would you rate your level of sexual desire
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C62185 (NCI Thesaurus Property)
C0242428 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Over the past 4 weeks, how would you rate your level of sexual desire
CL Item
Very Low/none At All (Very low/none at all)
CL Item
Low (Low)
C54722 (NCI Thesaurus)
C0205251 (UMLS 2011AA)
CL Item
Moderation (Moderate)
C61376 (NCI Thesaurus)
C1881878 (UMLS 2011AA)
CL Item
High (High)
C25227 (NCI Thesaurus)
C0205250 (UMLS 2011AA)
CL Item
Very High (Very high)
Item Group
Weight
PatientNormalWeightMeasurement
Item
What is your usual weight
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C14165 (NCI Thesaurus Property)
C0205307 (UMLS 2011AA Property)
C25208 (NCI Thesaurus Property)
C0043100 (UMLS 2011AA Property)
PatientWeightLossMeasurement
Item
How much weight have you lost in the past 6 months
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3445 (NCI Thesaurus Property)
C0043096 (UMLS 2011AA Property)

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial