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S0100 INDUCTION AND CONSOLIDATION TOXICITY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB46CC2-6DA8-4268-E034-0003BA12F5E7
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- 19.09.12 19.09.12 -
- 21.08.17 21.08.17 -
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19. September 2012
DOI
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Leukemia null Toxicity - S0100 INDUCTION AND CONSOLIDATION TOXICITY FORM - 2071052v3.0
Instructions: Please complete after each cycle of treatment. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.
- StudyEvent: S0100 INDUCTION AND CONSOLIDATION TOXICITY FORM
Ähnliche Modelle
Instructions: Please complete after each cycle of treatment. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.
- StudyEvent: S0100 INDUCTION AND CONSOLIDATION TOXICITY FORM
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item
Were toxicities assessed for this treatment cycle?
text
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Dateofmostrecenttoxicityassessment:
Item
Date of most recent toxicity assessment: (If No)
text
whyweretoxicitiesnotassessed?
Item
why were toxicities not assessed?
text
CTCCode
Item
Code
text
CL Item
Cardiac left ventricular function (Cardiac left ventricular function)
CL Item
Cardiac ischemia/infarction (Cardiac ischemia/infarction)
CL Item
Hypertension (Hypertension)
CL Item
Hypotension (Hypotension)
CL Item
Conjunctivitis (Conjunctivitis)
CL Item
Photophobia (Photophobia)
CL Item
Fever (Fever)
CL Item
Chills (Chills)
CL Item
Sweating (Sweating)
CL Item
Fatigue/malaise/lethargy (Fatigue/malaise/lethargy)
CL Item
Weight loss (Weight loss)
CL Item
Flushing (Flushing)
CL Item
Nausea (Nausea)
CL Item
Anorexia (Anorexia)
CL Item
Vomiting (Vomiting)
CL Item
Diarrhea (Diarrhea)
CL Item
Dehydration (Dehydration)
CL Item
Constipation (Constipation)
CL Item
Gastritis (Gastritis)
CL Item
Duodenal ulcer (Duodenal ulcer)
CL Item
Gastric ulcer (Gastric ulcer)
CL Item
Stomatitis/pharyngitis (Stomatitis/pharyngitis)
CL Item
Pancreatitis (Pancreatitis)
CL Item
Creatinine increase (Creatinine increase)
CL Item
Renal failure (Renal failure)
CL Item
Hemorrhage (Hemorrhage)
CL Item
Hematuria (Hematuria)
CL Item
Melana/GI bleeding (Melana/GI bleeding)
CL Item
Allergic reaction (Allergic reaction)
CL Item
Infection w/o neutropenia (Infection w/o neutropenia)
CL Item
Infection w/ neutropenia (Infection w/ neutropenia)
CL Item
Bilirubin increase (Bilirubin increase)
CL Item
SGOT increase (SGOT increase)
CL Item
SGPT increase (SGPT increase)
CL Item
Pneumonitis/infiltrates (Pneumonitis/infiltrates)
CL Item
Cough (Cough)
CL Item
ARDS (ARDS)
CL Item
Hypocalcemia (Hypocalcemia)
CL Item
Hyperkalemia (Hyperkalemia)
CL Item
Hyperglycemia (Hyperglycemia)
CL Item
Hypercalcemia (Hypercalcemia)
CL Item
Somnolence (Somnolence)
CL Item
Mood alteration-depression (Mood alteration-depression)
CL Item
Personality/ behavioral change (Personality/ behavioral change)
CL Item
Seizures (Seizures)
CL Item
Motor neuropathy (Motor neuropathy)
CL Item
Sensory neuropathy (Sensory neuropathy)
CL Item
Speech impairment (Speech impairment)
CL Item
Dizziness/lightheadedness (Dizziness/lightheadedness)
CL Item
Headache (Headache)
CL Item
Bone pain (Bone pain)
CL Item
Myalgia (Myalgia)
CL Item
Arthralgia (Arthralgia)
CL Item
Rash/desquamation (Rash/desquamation)
CL Item
Urticaria (Urticaria)
CL Item
Pruritis (Pruritis)
CL Item
Photosensitivity (Photosensitivity)
CL Item
Bruising (Bruising)
CL Item
Alopecia (Alopecia)
CL Item
Libido loss (Libido loss)
CL Item
Other (Other)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
Unrelated (unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (unlikely)
CL Item
Possible (possible)
C0332149 (NCI Metathesaurus)
CL Item
Probable (probable)
C0332148 (NCI Metathesaurus)
CL Item
Definite (definite)
Comments
Item
Notes
text
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitials
Item
Patient Initials (L, F, M)
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
CL Item
Current Phase Of Leukemia Treatment For Patient Is Induction (First Induction)
CL Item
Current Phase Of Leukemia Treatment For Patient Is Crossover (Cross-over Induction)
CL Item
Current Phase Of Leukemia Treatment For Patient Is Consolidation (Consolidation)