ID

24872

Description

S0100 ALLOGENEIC PBSCT TOXICITY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB3C5E9-6CF0-4330-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB3C5E9-6CF0-4330-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/21/17 8/21/17 -
Uploaded on

August 21, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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S0100 ALLOGENEIC PBSCT TOXICITY FORM

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

Alias
UMLS CUI-1
C0013221
UMLS CUI-2
C0040539
UMLS CUI-3
C0023418
UMLS CUI-4
C2242529
Were toxicities assessed for this treatment cycle?
Description

toxicities

Data type

boolean

Alias
UMLS CUI [1,1]
C0013221
UMLS CUI [1,2]
C0220825
UMLS CUI [2]
C2242529
Date of most recent toxicity assessment
Description

Date toxicity assessment

Data type

date

Alias
UMLS CUI [1,1]
C0013221
UMLS CUI [1,2]
C0220825
UMLS CUI [1,3]
C0011008
UMLS CUI [2]
C2242529
why were toxicities not assessed?
Description

whyweretoxicitiesnotassessed?

Data type

text

Alias
UMLS CUI [1,1]
C0013221
UMLS CUI [1,2]
C0220825
UMLS CUI [2]
C2242529
Code
Description

CTC Code

Data type

text

Alias
UMLS CUI [1,1]
C0805701
UMLS CUI [1,2]
C1516728
Toxicity
Description

CTC Adverse Event Term

Data type

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C1516728
Grade
Description

CTCAdverseEventGrade

Data type

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0441800
UMLS CUI [1,3]
C1516728
Treatment Relation
Description

CTCAdverseEventAttributionCode

Data type

integer

Alias
UMLS CUI [1,1]
C1706735
UMLS CUI [1,2]
C1516728
Notes
Description

comment

Data type

text

Alias
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C2242529
Ccrr Module For S0100 Induction And Consolidation Toxicity Form
Description

Ccrr Module For S0100 Induction And Consolidation Toxicity Form

Alias
UMLS CUI-1
C0013221
UMLS CUI-2
C0087111
UMLS CUI-3
C0023418
UMLS CUI-4
C2242529
SWOG Patient ID
Description

Patient ID

Data type

text

Alias
UMLS CUI [1]
C2348585
SWOG Study No.
Description

Study Number

Data type

text

Alias
UMLS CUI [1,1]
C0008976
UMLS CUI [1,2]
C0600091
Registration Step
Description

Registration Step

Data type

text

Alias
UMLS CUI-1
C1514821
Patient Initials
Description

Patient Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Institution/Affiliate
Description

Institution

Data type

text

Alias
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C0600091
Physician
Description

Treating Physician

Data type

text

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C25741
NCI Thesaurus ObjectClass-2
C25705
UMLS CUI [1]
C1710470
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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
C0013221 (UMLS CUI-1)
C0040539 (UMLS CUI-2)
C0023418 (UMLS CUI-3)
C2242529 (UMLS CUI-4)
toxicities
Item
Were toxicities assessed for this treatment cycle?
boolean
C0013221 (UMLS CUI [1,1])
C0220825 (UMLS CUI [1,2])
C2242529 (UMLS CUI [2])
Date toxicity assessment
Item
Date of most recent toxicity assessment
date
C0013221 (UMLS CUI [1,1])
C0220825 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
C2242529 (UMLS CUI [2])
whyweretoxicitiesnotassessed?
Item
why were toxicities not assessed?
text
C0013221 (UMLS CUI [1,1])
C0220825 (UMLS CUI [1,2])
C2242529 (UMLS CUI [2])
CTC Code
Item
Code
text
C0805701 (UMLS CUI [1,1])
C1516728 (UMLS CUI [1,2])
Item
Toxicity
integer
C0877248 (UMLS CUI [1,1])
C1516728 (UMLS CUI [1,2])
CL.2
Code List
Toxicity
CL Item
Cardiac left ventricular function (1)
(Comment:en)
CL Item
Cardiac ischemia/infarction (2)
(Comment:en)
CL Item
Hypertension (3)
(Comment:en)
CL Item
Hypotension (4)
(Comment:en)
CL Item
Conjunctivitis (5)
(Comment:en)
CL Item
Photophobia (6)
(Comment:en)
CL Item
Fever (7)
(Comment:en)
CL Item
Chills (8)
(Comment:en)
CL Item
Sweating (9)
(Comment:en)
CL Item
Fatigue/malaise/lethargy (10)
(Comment:en)
CL Item
Weight loss (11)
(Comment:en)
CL Item
Flushing (12)
(Comment:en)
CL Item
Nausea (13)
(Comment:en)
CL Item
Anorexia (14)
(Comment:en)
CL Item
Vomiting (15)
(Comment:en)
CL Item
Diarrhea (16)
(Comment:en)
CL Item
Dehydration (17)
(Comment:en)
CL Item
Constipation (18)
(Comment:en)
CL Item
Gastritis (19)
(Comment:en)
CL Item
Duodenal ulcer (20)
(Comment:en)
CL Item
Gastric ulcer (21)
(Comment:en)
CL Item
Stomatitis/pharyngitis (22)
(Comment:en)
CL Item
Pancreatitis (23)
(Comment:en)
CL Item
Creatinine increase (24)
(Comment:en)
CL Item
Renal failure (25)
(Comment:en)
CL Item
Hemorrhage (26)
(Comment:en)
CL Item
Hematuria (27)
(Comment:en)
CL Item
Melana/GI bleeding (28)
(Comment:en)
CL Item
Allergic reaction (29)
(Comment:en)
CL Item
Infection w/o neutropenia (30)
(Comment:en)
CL Item
Infection w/ neutropenia (31)
(Comment:en)
CL Item
Bilirubin increase (32)
(Comment:en)
CL Item
SGOT increase (33)
(Comment:en)
CL Item
SGPT increase (34)
(Comment:en)
CL Item
Pneumonitis/infiltrates (35)
(Comment:en)
CL Item
Cough (36)
(Comment:en)
CL Item
ARDS (37)
(Comment:en)
CL Item
Hypocalcemia (38)
(Comment:en)
CL Item
Hyperkalemia (39)
(Comment:en)
CL Item
Hyperglycemia (40)
(Comment:en)
CL Item
Hypercalcemia (41)
(Comment:en)
CL Item
Somnolence (42)
(Comment:en)
CL Item
Mood alteration-depression (43)
(Comment:en)
CL Item
Personality/ behavioral change (44)
(Comment:en)
CL Item
Seizures (45)
(Comment:en)
CL Item
Motor neuropathy (46)
(Comment:en)
CL Item
Sensory neuropathy (47)
(Comment:en)
CL Item
Speech impairment (48)
(Comment:en)
CL Item
Dizziness/lightheadedness (49)
(Comment:en)
CL Item
Headache (50)
(Comment:en)
CL Item
Bone pain (51)
(Comment:en)
CL Item
Myalgia (52)
(Comment:en)
CL Item
Arthralgia (53)
(Comment:en)
CL Item
Rash/desquamation (54)
(Comment:en)
CL Item
Urticaria (55)
(Comment:en)
CL Item
Pruritis (56)
(Comment:en)
CL Item
Photosensitivity (57)
(Comment:en)
CL Item
Bruising (58)
(Comment:en)
CL Item
Alopecia (59)
(Comment:en)
CL Item
Libido loss (60)
(Comment:en)
CL Item
Other (61)
(Comment:en)
Item
Grade
integer
C0877248 (UMLS CUI [1,1])
C0441800 (UMLS CUI [1,2])
C1516728 (UMLS CUI [1,3])
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
integer
C1706735 (UMLS CUI [1,1])
C1516728 (UMLS CUI [1,2])
CL.4
Code List
Treatment Relation
CL Item
Unrelated (1)
CL Item
Unlikely (2)
CL Item
Possible (3)
CL Item
Probable (4)
CL Item
Definite (5)
comment
Item
Notes
text
C0947611 (UMLS CUI [1,1])
C2242529 (UMLS CUI [1,2])
Item Group
Ccrr Module For S0100 Induction And Consolidation Toxicity Form
C0013221 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
C0023418 (UMLS CUI-3)
C2242529 (UMLS CUI-4)
Patient ID
Item
SWOG Patient ID
text
C2348585 (UMLS CUI [1])
Study Number
Item
SWOG Study No.
text
C0008976 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Registration Step
Item
Registration Step
text
C1514821 (UMLS CUI-1)
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Institution
Item
Institution/Affiliate
text
C1301943 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Treating Physician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C25741 (NCI Thesaurus ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1710470 (UMLS CUI [1])
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