ID

2118

Descrizione

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

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB38A2C-049E-4288-E034-0003BA12F5E7

Keywords

versioni (2)
  1. 19/09/12 19/09/12 -
  2. 22/08/17 22/08/17 -
Caricato su

19 settembre 2012

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Toxicity - S0100 CNS LEUKEMIA CRANIAL IRRADIATION TOXICITY FORM - 2071222v3.0

Inglese

No Instruction available.

1 moduli  
  1. StudyEvent: S0100 CNS LEUKEMIA CRANIAL IRRADIATION TOXICITY FORM
    1. No Instruction available.
Toxicity
Descrizione

Toxicity

Were toxicities assessed for this treatment cycle?
Descrizione

Weretoxicitiesassessedforthisreportinginterval?

Tipo di dati

text

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

SymptomAssessmentDate

Tipo di dati

date

why were toxicities not assessed?
Descrizione

whyweretoxicitiesnotassessed?

Tipo di dati

text

Code
Descrizione

CTCCode

Tipo di dati

text

Toxicity
Descrizione

CTCAdverseEventTerm

Tipo di dati

text

Other:
Descrizione

CTCAdverseEventTerm,Other

Tipo di dati

text

Grade
Descrizione

CTCAdverseEventGrade

Tipo di dati

text

Treatment Relation (* Treatment Relation codes:)
Descrizione

CTCAdverseEventAttributionCode

Tipo di dati

text

Comments
Descrizione

Comments

Ccrr Module For S0100 Cns Leukemia Cranial Irradiation Toxicity Form
Descrizione

Ccrr Module For S0100 Cns Leukemia Cranial Irradiation Toxicity Form

SWOG Patient ID
Descrizione

SWOGPatientID

Tipo di dati

text

SWOG Study No.
Descrizione

SWOGStudyNo.

Tipo di dati

text

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Patient Initials (L, F, M)
Descrizione

PatientInitials

Tipo di dati

text

Institution/Affiliate
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

Physician
Descrizione

TreatingPhysician

Tipo di dati

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
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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: S0100 CNS LEUKEMIA CRANIAL IRRADIATION TOXICITY FORM
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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
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
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)
Item Group
Comments
Item Group
Ccrr Module For S0100 Cns Leukemia Cranial Irradiation 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)
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