ID

2110

Description

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

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/22/17 8/22/17 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Toxicity - S0100 MAINTENANCE TOXICITY FORM - 2071610v3.0

English

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.

1 forms  
Toxicity
Description

Toxicity

Were toxicities assessed for this treatment cycle?
Description

Weretoxicitiesassessedforthisreportinginterval?

Data type

text

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

SymptomAssessmentDate

Data type

date

why were toxicities not assessed?
Description

whyweretoxicitiesnotassessed?

Data type

text

Code
Description

CTCCode

Data type

text

Toxicity
Description

CTCAdverseEventTerm

Data type

text

Other (toxicity)
Description

CTCAdverseEventTerm,Other

Data type

text

Grade
Description

CTCAdverseEventGrade

Data type

text

Treatment Relation (* Treatment Relation codes:)
Description

CTCAdverseEventAttributionCode

Data type

text

Notes
Description

Comments

Data type

text

Ccrr Module For S0100 Maintenance Toxicity Form
Description

Ccrr Module For S0100 Maintenance Toxicity Form

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F, M)
Description

PatientInitials

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Physician
Description

TreatingPhysician

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Cycle (check only one)
Description

CourseIdentification

Data type

text

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Similar models

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.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Toxicity
Item
Were toxicities assessed for this treatment cycle?
text
CL.1
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
CL.2
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
CL.3
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
CL.4
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
CL.5
Code List
Cycle (check only one)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
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