0 Bewertungen

ID

2110

Beschreibung

S0100 MAINTENANCE TOXICITY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB51D80-6426-43A7-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB51D80-6426-43A7-E034-0003BA12F5E7

Stichworte

  1. 19.09.12 19.09.12 -
  2. 22.08.17 22.08.17 -
Hochgeladen am

19. September 2012

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy

Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Itemgroup Kommentare für :

Item Kommentare für :


    Keine Kommentare

    Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

    Leukemia null Toxicity - S0100 MAINTENANCE TOXICITY FORM - 2071610v3.0

    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.

    Toxicity
    Beschreibung

    Toxicity

    Were toxicities assessed for this treatment cycle?
    Beschreibung

    Weretoxicitiesassessedforthisreportinginterval?

    Datentyp

    text

    Date of most recent toxicity assessment (If No,)
    Beschreibung

    SymptomAssessmentDate

    Datentyp

    date

    why were toxicities not assessed?
    Beschreibung

    whyweretoxicitiesnotassessed?

    Datentyp

    text

    Code
    Beschreibung

    CTCCode

    Datentyp

    text

    Toxicity
    Beschreibung

    CTCAdverseEventTerm

    Datentyp

    text

    Other (toxicity)
    Beschreibung

    CTCAdverseEventTerm,Other

    Datentyp

    text

    Grade
    Beschreibung

    CTCAdverseEventGrade

    Datentyp

    text

    Treatment Relation (* Treatment Relation codes:)
    Beschreibung

    CTCAdverseEventAttributionCode

    Datentyp

    text

    Notes
    Beschreibung

    Comments

    Datentyp

    text

    Ccrr Module For S0100 Maintenance Toxicity Form
    Beschreibung

    Ccrr Module For S0100 Maintenance Toxicity Form

    SWOG Patient ID
    Beschreibung

    SWOGPatientID

    Datentyp

    text

    SWOG Study No.
    Beschreibung

    SWOGStudyNo.

    Datentyp

    text

    Registration Step
    Beschreibung

    RegistrationStep

    Datentyp

    text

    Patient Initials (L, F, M)
    Beschreibung

    PatientInitials

    Datentyp

    text

    Institution/Affiliate
    Beschreibung

    MainMemberInstitution/Affiliate

    Datentyp

    text

    Physician
    Beschreibung

    TreatingPhysician

    Datentyp

    text

    Alias
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ObjectClass
    C25741 (undefined)
    UMLS 2011AA ObjectClass
    C0031831 (Physicians)
    SNOMED
    158965000
    LOINC
    LA18968-0
    NCI Thesaurus ObjectClass
    C25705 (undefined)
    UMLS 2011AA ObjectClass
    C1522326 (Treating)
    Cycle (check only one)
    Beschreibung

    CourseIdentification

    Datentyp

    text

    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.

    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    Toxicity
    Item
    Were toxicities assessed for this treatment cycle?
    text
    Code List
    Were toxicities assessed for this treatment cycle?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    SymptomAssessmentDate
    Item
    Date of most recent toxicity assessment (If No,)
    date
    whyweretoxicitiesnotassessed?
    Item
    why were toxicities not assessed?
    text
    CTCCode
    Item
    Code
    text
    Item
    Toxicity
    text
    Code List
    Toxicity
    CL Item
    Arrhythmia (Arrhythmia)
    CL Item
    Cardiac ischemia/infarction (Cardiac ischemia/infarction)
    CL Item
    Hypertension (Hypertension)
    CL Item
    Hypotension (Hypotension)
    CL Item
    Edema (Edema)
    CL Item
    Conjunctivitis (Conjunctivitis)
    CL Item
    Blurred vision (Blurred vision)
    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
    Nausea (Nausea)
    CL Item
    Anorexia (Anorexia)
    CL Item
    Vomiting (Vomiting)
    CL Item
    Diarrhea (Diarrhea)
    CL Item
    Constipation (Constipation)
    CL Item
    Taste disturbance (Taste disturbance)
    CL Item
    Gastritis (Gastritis)
    CL Item
    Duodenal ulcer (Duodenal ulcer)
    CL Item
    Gastric ulcer (Gastric ulcer)
    CL Item
    Stomatitis/pharyngitis (Stomatitis/pharyngitis)
    CL Item
    Esophagitis (Esophagitis)
    CL Item
    Pancreatitis (Pancreatitis)
    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
    Dyspnea (Dyspnea)
    CL Item
    Pneumonitis/infiltrates (Pneumonitis/infiltrates)
    CL Item
    Hypocalcemia (Hypocalcemia)
    CL Item
    Hyperkalemia (Hyperkalemia)
    CL Item
    Hyperglycemia (Hyperglycemia)
    CL Item
    Hypercalcemia (Hypercalcemia)
    CL Item
    Somnolence (Somnolence)
    CL Item
    Mood alteration -euphoric (Mood alteration -euphoric)
    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
    Dizziness/ lightheadedness (Dizziness/ lightheadedness)
    CL Item
    Insomnia (Insomnia)
    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
    Chest pain (Chest pain)
    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)
    CTCAdverseEventTerm,Other
    Item
    Other (toxicity)
    text
    Item
    Grade
    text
    Code List
    Grade
    CL Item
    1 (1)
    CL Item
    2 (2)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    5 (5)
    Item
    Treatment Relation (* Treatment Relation codes:)
    text
    Code List
    Treatment Relation (* Treatment Relation codes:)
    CL Item
    Unrelated (unrelated)
    C25328 (NCI Thesaurus)
    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
    Item Group
    Ccrr Module For S0100 Maintenance Toxicity Form
    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)
    Item
    Cycle (check only one)
    text
    Code List
    Cycle (check only one)
    CL Item
    1 (1)
    CL Item
    2 (2)
    CL Item
    3 (3)
    CL Item
    4 (4)

    Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

    Zum Video