ID

2046

Beschrijving

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

Trefwoorden

Geüploaded op

19 september 2012

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy

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

model
Details

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

1 Formulieren

StudyEvent: E2906 Abbreviated Comprehensive Geriatric Assessment Battery
1. 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)

Datatype

Alias

Header Module

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

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

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)

On Treatment Report Period

Item Group

On Treatment

TreatmentEvaluationPeriodType

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)

CL.1

Code List

On Treatment Report Period (Choose one)

CL Item

Baseline Step 1 (Baseline Step 1)

Unnamed1

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)

Unnamed2

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)

Mini Mental Examination Section

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)

GDS

Item Group

Gds

PatientAnhedoniaAssessmentInd-2

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)

CL.2

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)

PatientHappinessAssessmentInd-2

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)

CL.3

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)

PatientHopelessnessAssessmentInd-2

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)

CL.4

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)

PatientWorthlessnessAssessmentInd-2

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)

CL.5

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)

ADL

Item Group

Adl

BathingPatientAssistanceAssessmentType

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)

CL.6

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)

TransferPatientAssistanceAssessmentType

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)

CL.7

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)

IncontinencePatientAssistanceAssessmentType

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)

CL.8

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)

ShoppingPatientAssistanceAssessmentType

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)

CL.9

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)

FoodPreparationPatientAssistanceAssessmentType

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)

CL.10

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)

HouseholdActivityPatientAssistanceAssessmentType

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)

CL.11

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)

WashPatientAssistanceAssessmentType

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)

CL.12

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)

MOS Social Support Survey - Emotional/Informational Support

Item Group

Section Ii - Social Support

QualityofLifePersonDiscussionAssessmentScale

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)

CL.13

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)

QualityofLifePersonAdvisingAssessmentScale

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)

CL.17

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)

QualityofLifePersonAdvisingAssessmentScale

Item

Someone whose advice you really want

text

CL.17

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)

QualityofLifePersonConfidenceAssessmentScale

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)

CL.18

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)

QualityofLifePersonConfidenceAssessmentScale

Item

Someone to share your most private worries and fears with

text

CL.18

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)

QualityofLifePersonInformationAssessmentScale

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)

CL.19

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)

QualityofLifePersonInformationAssessmentScale

Item

Someone to turn to for suggestions about how to deal with a personal problem

text

CL.19

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)

QualityofLifePersonProblemAppreciationAssessmentScale

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)

CL.20

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)

MOS Social Support Survey - Tangible support

Item Group

Section Ii - Social Support

QualityofLifePersonBedRestAssessmentScale

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)

CL.21

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)

QualityofLifePersonPhysicianOfficeDeliveryAssessment

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)

CL.22

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)

QualityofLifePersonFoodPreparationAssessmentScale

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)

CL.23

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)

QualityofLifeHouseholdActivitySupportAssessmentScale

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)

CL.24

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)

Comorbidity Questionnaire

Item Group

Comorbidity Questionnaire

PatientPriorMyocardialInfarctionInd-3

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)

CL.25

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)

CongestiveHeartFailureHistoryInd-2

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)

CL.26

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)

HeartInvolvedInd-3

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)

CL.27

Code List

Do you have other heart disease

CL Item

No (NO)

CL Item

Yes (YES)

OtherPeripheralArteryDiseasePresentInd-3

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)

CL.28

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)

PatientTransientIschemicAttackCerebrovascularAccidentPersonalMedicalHistoryInd-2

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)

CL.29

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)

PatientCerebrovascularAccidentMovementDifficultyPresentInd-2

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)

CL.30

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)

AsthmaHistoryInd-2

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)

CL.31

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)

AsthmaMedicationPersonalMedicalHistoryIndicator

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)

CL.32

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)

DiseaseEmphysemaBronchitisPresentInd-3

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)

CL.33

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)

TherapeuticProcedureDiseaseEmphysemaBronchitisPresentIndicator

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)

CL.34

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)

Comorbidity Questionnaire1

Item Group

Comorbidity Questionnaire1

DiseaseStomachPresentInd-3

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)

CL.35

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)

DiabetesMellitusDiseasesandDisordersMedicationBaselineUseInd-2

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)

CL.36

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)

DiabetesMellitusCurrentTherapeuticProcedureType

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)

CL.37

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)

PatientDiabetesOrganComplicationPersonalMedicalHistoryType

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)

CL.38

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)

KidneyDiseasePresentType

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)

CL.39

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)

PatientArthritisPersonalMedicalHistoryInd-3

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)

CL.40

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)

ConcomitantMedicationUseInd-3

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)

CL.41

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)

ConcomitantDiseasePersonalMedicalHistoryType

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)

CL.42

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)

PersonDentistVisitType

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)

CL.43

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)

Medications/Sexual Function

Item Group

Medications/sexual Function

ConcomitantPrescriptionMedicationUseNumber

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)

CL.44

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)

ConcomitantMedicationUseNumber

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)

CL.45

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)

SexBehaviorQualityofLifeSexualIntercourseOccurrenceAssessmentScale

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)

CL.46

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)

SexBehaviorQualityofLifeOverallSatisfactionAssessmentScale

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)

CL.47

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)

Weight

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)

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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

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