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ID
2094
Beschreibung
S0100 ALLOGENEIC PBSCT TOXICITY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB3C5E9-6CF0-4330-E034-0003BA12F5E7
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- 19.09.12 19.09.12 -
- 21.08.17 21.08.17 -
Hochgeladen am
19. September 2012
DOI
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Leukemia null Toxicity - S0100 ALLOGENEIC PBSCT TOXICITY FORM - 2071336v3.0
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- StudyEvent: S0100 ALLOGENEIC PBSCT TOXICITY FORM
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- StudyEvent: S0100 ALLOGENEIC PBSCT 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)
SymptomAssessmentDate
Item
Date of most recent toxicity assessment
date
whyweretoxicitiesnotassessed?
Item
why were toxicities not assessed?
text
CTCCode
Item
Code
text
CL Item
Arrhythmia (Arrhythmia)
CL Item
Cardiac ischemia/infarction (Cardiac ischemia/infarction)
CL Item
Hypotension (Hypotension)
CL Item
Edema (Edema)
CL Item
Fever (Fever)
CL Item
Chills (Chills)
CL Item
Sweating (Sweating)
CL Item
Fatigue/malaise/lethargy (Fatigue/malaise/lethargy)
CL Item
Nausea (Nausea)
CL Item
Anorexia (Anorexia)
CL Item
Vomiting (Vomiting)
CL Item
Diarrhea (Diarrhea)
CL Item
Constipation (Constipation)
CL Item
Salivary gland changes (Salivary gland changes)
CL Item
Taste disturbance (Taste disturbance)
CL Item
Gastritis (Gastritis)
CL Item
Stomatitis/pharyngitis (Stomatitis/pharyngitis)
CL Item
Esophagitis (Esophagitis)
CL Item
Renal failure (Renal failure)
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
Dyspnea (Dyspnea)
CL Item
Pneumonitis/infiltrates (Pneumonitis/infiltrates)
CL Item
Pleural effusion (Pleural effusion)
CL Item
Somnolence (Somnolence)
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
Abdominal pain (Abdominal pain)
CL Item
Rash/desquamation (Rash/desquamation)
CL Item
Urticaria (Urticaria)
CL Item
Pruritis (Pruritis)
CL Item
Pigmentation changes (Pigmentation changes)
CL Item
Alopecia (Alopecia)
CL Item
RT-dermatitis (RT-dermatitis)
CL Item
Female sterility (Female sterility)
CL Item
Male infertility (Male infertility)
CTCAdverseEventTerm,Other
Item
Other:
text
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
Comments
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)