ID

2126

Descripción

S0100 POST- PBSCT TOXICITY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB50362-4F16-439A-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB50362-4F16-439A-E034-0003BA12F5E7

Palabras clave

Versiones (2)
  1. 19/9/12 19/9/12 - Philipp Bruland
  2. 22/8/17 22/8/17 -
Subido en

19 de septiembre de 2012

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Toxicity - S0100 POST- PBSCT TOXICITY FORM - 2071464v3.0

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: S0100 POST- PBSCT TOXICITY FORM
    1. No Instruction available.
Toxicity
Descripción

Toxicity

Were toxicities assessed for this treatment cycle?
Descripción

Weretoxicitiesassessedforthisreportinginterval?

Tipo de datos

text

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

SymptomAssessmentDate

Tipo de datos

date

why were toxicities not assessed?
Descripción

whyweretoxicitiesnotassessed?

Tipo de datos

text

Code
Descripción

CTCCode

Tipo de datos

text

Toxicity
Descripción

CTCAdverseEventTerm

Tipo de datos

text

Other (toxicity)
Descripción

CTCAdverseEventTerm,Other

Tipo de datos

text

Grade
Descripción

CTCAdverseEventGrade

Tipo de datos

text

Treatment Relation
Descripción

CTCAdverseEventAttributionCode

Tipo de datos

text

Comments
Descripción

Comments

Tipo de datos

text

Ccrr Module For S0100 Post- Pbsct Toxicity Form
Descripción

Ccrr Module For S0100 Post- Pbsct Toxicity Form

SWOG Patient ID
Descripción

SWOGPatientID

Tipo de datos

text

SWOG Study No.
Descripción

SWOGStudyNo.

Tipo de datos

text

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Patient Initials (L, F, M)
Descripción

PatientInitials

Tipo de datos

text

Institution/Affiliate
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Physician
Descripción

TreatingPhysician

Tipo de datos

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 formularios
  1. StudyEvent: S0100 POST- PBSCT TOXICITY FORM
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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
Arrythmia (Arrythmia)
CL Item
Hypertension (Hypertension)
CL Item
Hypotension (Hypotension)
CL Item
Thrombosis/embolism (Thrombosis/embolism)
CL Item
Edema (Edema)
CL Item
Phlebitis (Phlebitis)
CL Item
Acute vascular leak syndrome (Acute vascular leak syndrome)
CL Item
Blurred vision (Blurred vision)
CL Item
Fever (Fever)
CL Item
Chills (Chills)
CL Item
Sweating (Sweating)
CL Item
Fatigue/malaise/lethargy (Fatigue/malaise/lethargy)
CL Item
Flushing (Flushing)
CL Item
Nausea (Nausea)
CL Item
Anorexia (Anorexia)
CL Item
Dyspepsia/heartburn (Dyspepsia/heartburn)
CL Item
Vomiting (Vomiting)
CL Item
Diarrhea (Diarrhea)
CL Item
Stomatitis/pharyngitis (Stomatitis/pharyngitis)
CL Item
Creatinine increase (Creatinine increase)
CL Item
Renal failure (Renal failure)
CL Item
Hematuria (Hematuria)
CL Item
Melana/GI bleeding (Melana/GI bleeding)
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
Cough (Cough)
CL Item
Hyperkalemia (Hyperkalemia)
CL Item
Hyperglycemia (Hyperglycemia)
CL Item
Hypomagnesemia (Hypomagnesemia)
CL Item
Hyperuricemia (Hyperuricemia)
CL Item
Muscle weakness (not neuropathy) (Muscle weakness (not neuropathy))
CL Item
Somnolence (Somnolence)
CL Item
Mood alteration -depression (Mood alteration -depression)
CL Item
Personality/behavioral change (Personality/behavioral change)
CL Item
Seizures (Seizures)
CL Item
Tremor (Tremor)
CL Item
Motor neuropathy (Motor neuropathy)
CL Item
Speech impairment (Speech impairment)
CL Item
Sensory neuropathy (Sensory neuropathy)
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
Injection site reaction (Injection site reaction)
CL Item
Rash/desquamation (Rash/desquamation)
CL Item
Urticaria (Urticaria)
CL Item
Pruritis (Pruritis)
CL Item
Photosensitivity (Photosensitivity)
CL Item
Pigmentation changes (Pigmentation changes)
CL Item
Bruising (Bruising)
CL Item
Alopecia (Alopecia)
CL Item
Libido loss (Libido loss)
CL Item
Menses changes (Menses changes)
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
text
CL.4
Code List
Treatment Relation
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
Comments
text
Item Group
Ccrr Module For S0100 Post- Pbsct 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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