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ID
2118
Description
S0100 CNS LEUKEMIA CRANIAL IRRADIATION TOXICITY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB38A2C-049E-4288-E034-0003BA12F5E7
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- 9/19/12 9/19/12 -
- 8/22/17 8/22/17 -
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September 19, 2012
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Creative Commons BY-NC 3.0 Legacy
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Leukemia null Toxicity - S0100 CNS LEUKEMIA CRANIAL IRRADIATION TOXICITY FORM - 2071222v3.0
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- StudyEvent: S0100 CNS LEUKEMIA CRANIAL IRRADIATION TOXICITY FORM
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- StudyEvent: S0100 CNS LEUKEMIA CRANIAL IRRADIATION TOXICITY FORM
Name
Type
Description | Question | Decode (Coded Value)
Data type
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 (If No,)
date
whyweretoxicitiesnotassessed?
Item
why were toxicities not assessed?
text
CTCCode
Item
Code
text
CL Item
Hypertension (Hypertension)
CL Item
Hypotension (Hypotension)
CL Item
Cataract (Cataract)
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
Mouth dryness (Mouth dryness)
CL Item
Pneumonitis/infiltrates (Pneumonitis/infiltrates)
CL Item
Cough (Cough)
CL Item
Confusion (Confusion)
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
Speech impairment (Speech impairment)
CL Item
Dizziness/lightheadedness (Dizziness/lightheadedness)
CL Item
Headache (Headache)
CL Item
Myalgia (Myalgia)
CL Item
Arthralgia (Arthralgia)
CL Item
Rash/desquamation (Rash/desquamation)
CL Item
Alopecia (Alopecia)
CL Item
RT-dermatitis (RT-dermatitis)
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)
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)