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11404

Description

Southwest Oncology Group Medical Conditions Questionnaire Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF6FCD-888E-36E1-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF6FCD-888E-36E1-E034-080020C9C0E0

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

July 3, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Southwest Oncology Group Medical Conditions Questionnaire

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Southwest Oncology Group Medical Conditions Questionnaire
      1. No Instruction available.
    SWOG clinical trial administrative data
    Description

    SWOG clinical trial administrative data

    SWOG Patient ID
    Description

    SWOGPatientID

    Data type

    text

    SWOG Study No.
    Description

    SWOGStudyNo.

    Data type

    text

    Registration Step
    Description

    RegistrationStep

    Data type

    text

    Patient Initials (L, F M)
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Date
    Description

    Date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Institution/Affiliate
    Description

    MainMemberInstitution/Affiliate

    Data type

    text

    Physician
    Description

    RegisteredInvestigator

    Data type

    text

    Medical Conditions
    Description

    Medical Conditions

    Have you ever had a heart attack?
    Description

    Haveyoueverhadaheartattack?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Have you ever been treated for heart failure? (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
    Description

    Haveyoueverbeentreatedforheartfailure?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Have you had an operation to unclog or bypass the arteries in your legs?
    Description

    LowerExtremityPatientArteryBypassPersonalMedicalHistoryInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Metathesaurus ObjectClass
    C0023216
    NCI Thesaurus Property
    C12372
    UMLS 2011AA Property
    C0003842
    NCI Thesaurus Property-2
    C18772
    UMLS 2011AA Property-2
    C0262926
    NCI Thesaurus Property-3
    C15723
    UMLS 2011AA Property-3
    C0741847
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Have you had an operation or procedure to unclog or bypass the arteries in your heart?
    Description

    HeartPatientArteryBypassPersonalMedicalHistoryInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C12727
    UMLS 2011AA ObjectClass-2
    C0018787
    NCI Thesaurus Property
    C12372
    UMLS 2011AA Property
    C0003842
    NCI Thesaurus Property-2
    C18772
    UMLS 2011AA Property-2
    C0262926
    NCI Thesaurus Property-3
    C15723
    UMLS 2011AA Property-3
    C0741847
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)?
    Description

    Haveyouhadastroke,cerebrovascularaccident,bloodclotorbleedinginthebrain,ortransientischemicattack(TIA)?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    If you have had any of these problems, do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident?
    Description

    Ifyouhavehadanyoftheseproblems,doyouhavedifficultymovinganarmorlegasaresultofthestrokeorcerebrovascularaccident?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Do you have asthma?
    Description

    Doyouhaveasthma?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    If you have asthma, do you take medicines for your asthma?
    Description

    Ifyouhaveasthma,doyoutakemedicinesforyourasthma?

    Data type

    text

    Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease?
    Description

    Doyouhaveemphysema,chronicbronchitis,orchronicobstructivelungdisease?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    If you have any of these lung diseases, do you take medicines for your condition?
    Description

    Ifyouhaveanyoftheselungdiseases,doyoutakemedicinesforyourcondition?

    Data type

    text

    Do you have stomach ulcers, or peptic ulcer disease?
    Description

    Doyouhavestomachulcers,orpepticulcerdisease?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C18772
    UMLS 2011AA Property
    C0262926
    NCI Thesaurus Property-2
    C25757
    UMLS 2011AA Property-2
    C0041582
    If you have any of these conditions, has it been diagnosed by a doctor looking into your stomach through a scope, or by asking you to swallow a chalky dye and then having x-rays taken?
    Description

    Ifyouhaveanyoftheseconditions,hasitbeendiagnosedbyadoctorlookingintoyourstomachthroughascope,orbyaskingyoutoswallowachalkydyeandthenhavingx-raystaken?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Do you have diabetes (high blood sugar)?
    Description

    Doyouhavediabetes(highbloodsugar)?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    If you have diabetes, are you being treated for it?
    Description

    Ifyouhavediabetes,areyoubeingtreatedforit?

    Data type

    text

    If you have diabetes, has it caused problems with your kidneys?
    Description

    Ifyouhavediabetes,hasitcausedproblemswithyourkidneys?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    If you have diabetes, has it caused problems with your eyes, treated by an ophthalmologist?
    Description

    Ifyouhavediabetes,hasitcausedproblemswithyoureyes,treatedbyanophthalmologist?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Have you ever had poor kidney function (blood tests show high creatinine)?
    Description

    Haveyoueverhadpoorkidneyfunction(bloodtestsshowhighcreatinine)?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Have you have used hemodialysis or peritoneal dialysis?
    Description

    Haveyouhaveusedhemodialysisorperitonealdialysis?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Have you ever received a kidney transplantation?
    Description

    Haveyoueverreceivedakidneytransplantation?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Do you have rheumatoid arthritis?
    Description

    Doyouhaverheumatoidarthritis?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    If you have rheumatoid arthritis, do you take medications for it regularly?
    Description

    Ifyouhaverheumatoidarthritis,doyoutakemedicationsforitregularly?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Do you have lupus (systemic lupus erythematosus)?
    Description

    Doyouhavelupus(systemiclupuserythematosus)?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Do you have polymyalgia rheumatica (inflammatory disorder causing joint and muscle pain)?
    Description

    Doyouhavepolymyalgiarheumatica(inflammatorydisordercausingjointandmusclepain)?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Do you have Alzheimer's Disease, or another form of dementia?
    Description

    DoyouhaveAlzheimer'sDisease,oranotherformofdementia?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Do you have cirrhosis, or serious liver damage?
    Description

    Doyouhavecirrhosis,orseriousliverdamage?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Have you had any type of cancer (other than common skin cancer such as basal or squamous cell skin cancer) that was successfully treated more than 5 years ago?
    Description

    Haveyouhadanytypeofcancer(otherthancommonskincancersuchasbasalorsquamouscellskincancer)thatwassuccessfullytreatedmorethan5yearsago?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    If you were treated for cancer more than 5 years ago had the cancer spread, or metastasized, to other parts of your body?
    Description

    Ifyouweretreatedforcancermorethan5yearsagohadthecancerspread,ormetastasized,tootherpartsofyourbody?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Do you have AIDS (acquired immunodeficiency syndrome)?
    Description

    PatientAcquiredImmunodeficiencySyndromeAssessmentInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property-2
    C2851
    UMLS 2011AA Property-2
    C0001175
    Have you had weight loss that required medical treatment?
    Description

    Haveyouhadweightlossthatrequiredmedicaltreatment?

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Ccrr Module For Southwest Oncology Group Medical Conditions Questionnaire
    Description

    Ccrr Module For Southwest Oncology Group Medical Conditions Questionnaire

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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: Southwest Oncology Group Medical Conditions Questionnaire
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    SWOG clinical trial administrative data
    SWOGPatientID
    Item
    SWOG Patient ID
    text
    SWOGStudyNo.
    Item
    SWOG Study No.
    text
    RegistrationStep
    Item
    Registration Step
    text
    Patient Initials
    Item
    Patient Initials (L, F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Date
    Item
    Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    MainMemberInstitution/Affiliate
    Item
    Institution/Affiliate
    text
    RegisteredInvestigator
    Item
    Physician
    text
    Item Group
    Medical Conditions
    Haveyoueverhadaheartattack?
    Item
    Have you ever had a heart attack?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Haveyoueverbeentreatedforheartfailure?
    Item
    Have you ever been treated for heart failure? (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    LowerExtremityPatientArteryBypassPersonalMedicalHistoryInd-2
    Item
    Have you had an operation to unclog or bypass the arteries in your legs?
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C0023216 (NCI Metathesaurus ObjectClass)
    C12372 (NCI Thesaurus Property)
    C0003842 (UMLS 2011AA Property)
    C18772 (NCI Thesaurus Property-2)
    C0262926 (UMLS 2011AA Property-2)
    C15723 (NCI Thesaurus Property-3)
    C0741847 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    HeartPatientArteryBypassPersonalMedicalHistoryInd-3
    Item
    Have you had an operation or procedure to unclog or bypass the arteries in your heart?
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C12727 (NCI Thesaurus ObjectClass-2)
    C0018787 (UMLS 2011AA ObjectClass-2)
    C12372 (NCI Thesaurus Property)
    C0003842 (UMLS 2011AA Property)
    C18772 (NCI Thesaurus Property-2)
    C0262926 (UMLS 2011AA Property-2)
    C15723 (NCI Thesaurus Property-3)
    C0741847 (UMLS 2011AA Property-3)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    Haveyouhadastroke,cerebrovascularaccident,bloodclotorbleedinginthebrain,ortransientischemicattack(TIA)?
    Item
    Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Ifyouhavehadanyoftheseproblems,doyouhavedifficultymovinganarmorlegasaresultofthestrokeorcerebrovascularaccident?
    Item
    If you have had any of these problems, do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Doyouhaveasthma?
    Item
    Do you have asthma?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Item
    If you have asthma, do you take medicines for your asthma?
    text
    CL.8
    Code List
    If you have asthma, do you take medicines for your asthma?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, Only With Flare-ups Of My Asthma (Yes, only with flare-ups of my asthma)
    CL Item
    Yes, I Take Medicines Regularly, Even When I'm Not Having A Flare-up (Yes, I take medicines regularly, even when I'm not having a flare-up)
    Doyouhaveemphysema,chronicbronchitis,orchronicobstructivelungdisease?
    Item
    Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Item
    If you have any of these lung diseases, do you take medicines for your condition?
    text
    CL.10
    Code List
    If you have any of these lung diseases, do you take medicines for your condition?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, Only With Flare-ups Of My Asthma (Yes, only with flare-ups of my asthma)
    CL Item
    Yes, I Take Medicines Regularly, Even When I'm Not Having A Flare-up (Yes, I take medicines regularly, even when I'm not having a flare-up)
    Doyouhavestomachulcers,orpepticulcerdisease?
    Item
    Do you have stomach ulcers, or peptic ulcer disease?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C18772 (NCI Thesaurus Property)
    C0262926 (UMLS 2011AA Property)
    C25757 (NCI Thesaurus Property-2)
    C0041582 (UMLS 2011AA Property-2)
    Ifyouhaveanyoftheseconditions,hasitbeendiagnosedbyadoctorlookingintoyourstomachthroughascope,orbyaskingyoutoswallowachalkydyeandthenhavingx-raystaken?
    Item
    If you have any of these conditions, has it been diagnosed by a doctor looking into your stomach through a scope, or by asking you to swallow a chalky dye and then having x-rays taken?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Doyouhavediabetes(highbloodsugar)?
    Item
    Do you have diabetes (high blood sugar)?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Item
    If you have diabetes, are you being treated for it?
    text
    CL.14
    Code List
    If you have diabetes, are you being treated for it?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, Treated By Modifying My Diet (Yes, treated by modifying my diet)
    CL Item
    Yes, Treated By Medications Taken By Mouth (Yes, treated by medications taken by mouth)
    CL Item
    Yes, Treated By Insuling Injections (Yes, treated by insuling injections)
    Ifyouhavediabetes,hasitcausedproblemswithyourkidneys?
    Item
    If you have diabetes, has it caused problems with your kidneys?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Ifyouhavediabetes,hasitcausedproblemswithyoureyes,treatedbyanophthalmologist?
    Item
    If you have diabetes, has it caused problems with your eyes, treated by an ophthalmologist?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Haveyoueverhadpoorkidneyfunction(bloodtestsshowhighcreatinine)?
    Item
    Have you ever had poor kidney function (blood tests show high creatinine)?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Haveyouhaveusedhemodialysisorperitonealdialysis?
    Item
    Have you have used hemodialysis or peritoneal dialysis?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Haveyoueverreceivedakidneytransplantation?
    Item
    Have you ever received a kidney transplantation?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Doyouhaverheumatoidarthritis?
    Item
    Do you have rheumatoid arthritis?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Ifyouhaverheumatoidarthritis,doyoutakemedicationsforitregularly?
    Item
    If you have rheumatoid arthritis, do you take medications for it regularly?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Doyouhavelupus(systemiclupuserythematosus)?
    Item
    Do you have lupus (systemic lupus erythematosus)?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Doyouhavepolymyalgiarheumatica(inflammatorydisordercausingjointandmusclepain)?
    Item
    Do you have polymyalgia rheumatica (inflammatory disorder causing joint and muscle pain)?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    DoyouhaveAlzheimer'sDisease,oranotherformofdementia?
    Item
    Do you have Alzheimer's Disease, or another form of dementia?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Doyouhavecirrhosis,orseriousliverdamage?
    Item
    Do you have cirrhosis, or serious liver damage?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Haveyouhadanytypeofcancer(otherthancommonskincancersuchasbasalorsquamouscellskincancer)thatwassuccessfullytreatedmorethan5yearsago?
    Item
    Have you had any type of cancer (other than common skin cancer such as basal or squamous cell skin cancer) that was successfully treated more than 5 years ago?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Ifyouweretreatedforcancermorethan5yearsagohadthecancerspread,ormetastasized,tootherpartsofyourbody?
    Item
    If you were treated for cancer more than 5 years ago had the cancer spread, or metastasized, to other parts of your body?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    PatientAcquiredImmunodeficiencySyndromeAssessmentInd-3
    Item
    Do you have AIDS (acquired immunodeficiency syndrome)?
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C2851 (NCI Thesaurus Property-2)
    C0001175 (UMLS 2011AA Property-2)
    Haveyouhadweightlossthatrequiredmedicaltreatment?
    Item
    Have you had weight loss that required medical treatment?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Item Group
    Ccrr Module For Southwest Oncology Group Medical Conditions Questionnaire
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