0 Beoordelingen

ID

24885

Beschrijving

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

Trefwoorden

  1. 19-09-12 19-09-12 -
  2. 22-08-17 22-08-17 -
Geüploaded op

22 augustus 2017

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy

Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Itemgroep Commentaren voor :

Item Commentaren voor :


    Geen commentaren

    U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

    S0100 POST- PBSCT TOXICITY FORM

    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.

    Toxicity
    Beschrijving

    Toxicity

    Alias
    UMLS CUI-1
    C0013221
    UMLS CUI-2
    C0040539
    UMLS CUI-3
    C2242529
    UMLS CUI-4
    C1882428
    UMLS CUI-5
    C0023418
    Were toxicities assessed for this treatment cycle?
    Beschrijving

    toxicities

    Datatype

    boolean

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

    Date toxicity assessment

    Datatype

    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?
    Beschrijving

    whyweretoxicitiesnotassessed?

    Datatype

    text

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

    CTC Code

    Datatype

    text

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

    CTC Adverse Event Term

    Datatype

    integer

    Alias
    UMLS CUI [1,1]
    C0877248
    UMLS CUI [1,2]
    C1516728
    UMLS CUI [2]
    C0079172
    Grade
    Beschrijving

    CTCAdverseEventGrade

    Datatype

    integer

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

    CTCAdverseEventAttributionCode

    Datatype

    integer

    Alias
    UMLS CUI [1,1]
    C1706735
    UMLS CUI [1,2]
    C1516728
    UMLS CUI [2]
    C0079172
    Notes
    Beschrijving

    comment

    Datatype

    text

    Alias
    UMLS CUI [1,1]
    C0947611
    UMLS CUI [1,2]
    C0013221
    UMLS CUI [1,3]
    C2242529
    Ccrr Module For S0100 Post- Pbsct Toxicity Form
    Beschrijving

    Ccrr Module For S0100 Post- Pbsct Toxicity Form

    Alias
    UMLS CUI-1
    C0013221
    UMLS CUI-2
    C0040539
    UMLS CUI-3
    C2242529
    UMLS CUI-4
    C1882428
    UMLS CUI-5
    C0023418
    SWOG Patient ID
    Beschrijving

    Patient ID

    Datatype

    text

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

    Study Number

    Datatype

    text

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

    Registration Step

    Datatype

    text

    Alias
    UMLS CUI-1
    C1514821
    Patient Initials
    Beschrijving

    Patient Initials

    Datatype

    text

    Alias
    UMLS CUI [1]
    C2986440
    Institution/Affiliate
    Beschrijving

    Institution

    Datatype

    text

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

    Treating Physician

    Datatype

    text

    Alias
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C25741
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS CUI [1]
    C1710470

    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.

    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Toxicity
    C0013221 (UMLS CUI-1)
    C0040539 (UMLS CUI-2)
    C2242529 (UMLS CUI-3)
    C1882428 (UMLS CUI-4)
    C0023418 (UMLS CUI-5)
    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])
    C0079172 (UMLS CUI [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
    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
    Weight loss (11)
    CL Item
    Melana/GI bleeding (28)
    CL Item
    Allergic reaction (29)
    CL Item
    Infection w/o neutropenia (30)
    CL Item
    Infection w/ neutropenia (31)
    CL Item
    Bilirubin increase (32)
    CL Item
    SGOT increase (33)
    CL Item
    SGPT increase (34)
    CL Item
    Pneumonitis/infiltrates (35)
    CL Item
    Cough (36)
    CL Item
    ARDS (37)
    CL Item
    Hypocalcemia (38)
    CL Item
    Hyperkalemia (39)
    CL Item
    Hyperglycemia (40)
    CL Item
    Hypercalcemia (41)
    CL Item
    Somnolence (42)
    CL Item
    Mood alteration-depression (43)
    CL Item
    Personality/ behavioral change (44)
    CL Item
    Seizures (45)
    CL Item
    Motor neuropathy (46)
    CL Item
    Sensory neuropathy (47)
    CL Item
    Speech impairment (48)
    CL Item
    Dizziness/lightheadedness (49)
    CL Item
    Headache (50)
    CL Item
    Bone pain (51)
    CL Item
    Myalgia (52)
    CL Item
    Arthralgia (53)
    CL Item
    Rash/desquamation (54)
    CL Item
    Urticaria (55)
    CL Item
    Pruritis (56)
    CL Item
    Photosensitivity (57)
    CL Item
    Bruising (58)
    CL Item
    Alopecia (59)
    CL Item
    Libido loss (60)
    CL Item
    Other (61)
    Item
    Grade
    integer
    C0877248 (UMLS CUI [1,1])
    C0441800 (UMLS CUI [1,2])
    C1516728 (UMLS CUI [1,3])
    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])
    C0079172 (UMLS CUI [2])
    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])
    C0013221 (UMLS CUI [1,2])
    C2242529 (UMLS CUI [1,3])
    Item Group
    Ccrr Module For S0100 Post- Pbsct Toxicity Form
    C0013221 (UMLS CUI-1)
    C0040539 (UMLS CUI-2)
    C2242529 (UMLS CUI-3)
    C1882428 (UMLS CUI-4)
    C0023418 (UMLS CUI-5)
    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])

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial