ID

25267

Description

AMC-075 Pregnancy Report Form (PRF) Vorinostat and Combination Chemotherapy With Rituximab in Treating Patients With Previously Untreated HIV-Related Diffuse Large B-Cell Non-Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0F9B852-8D06-8306-E040-BB89AD434EB4

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0F9B852-8D06-8306-E040-BB89AD434EB4

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/29/17 8/29/17 -
Uploaded on

August 29, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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AMC-075 Pregnancy Report Form (PRF)

English

For date fields, if the month and year are known, but the exact date is not, please enter "15" for the day.

1 forms  
Header - Pregnancy Report Form
Description

Header - Pregnancy Report Form

Alias
UMLS CUI-1
C1320722
UMLS CUI-2
C0032961
UMLS CUI-3
C1332051
Sequence number
Description

SequentialFormSubmissionCount

Data type

integer

Alias
NCI Thesaurus ObjectClass
C19464
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus ObjectClass-2
C49153
NCI Thesaurus Property
C25694
UMLS CUI [1]
C2348184
Current Pregnancy Information
Description

Current Pregnancy Information

Alias
UMLS CUI-1
C0032961
UMLS CUI-2
C1332051
Date of pregnancy test
Description

Patient Most Recent Pregnancy Test Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C16960
NCI Metathesaurus Property
C0032976
NCI Thesaurus Property
C25577
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C0011008
Type of pregnancy test
Description

PregnancyLaboratoryProcedurePerformedType

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus Property
C38000
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus ObjectClass-2
C25294
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C0332307
If a urine test was used to make the initial diagnosis, was the diagnosis confirmed by a serum test
Description

Patient Serum Pregnancy Test

Data type

integer

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C13325
NCI Thesaurus Property-2
C92949
UMLS CUI [1]
C0430060
Serum pregnancy test date
Description

PatientSerumPregnancyTestDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C13325
UMLS 2011AA Property
C0229671
NCI Thesaurus Property-2
C92949
Date of last menstrual period
Description

LastMenstrualCycleOccurrenceDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25551
NCI Thesaurus Property
C25275
NCI Thesaurus ObjectClass-2
C16838
UMLS CUI [1]
C0425932
Estimated date of conception
Description

PatientEstimatedConceptionDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25498
NCI Thesaurus Property-2
C16465
UMLS CUI [1,1]
C0009637
UMLS CUI [1,2]
C0750572
UMLS CUI [1,3]
C0011008
Due Date
Description

Pregnancy Delivery Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25742
NCI Thesaurus Property
C61560
UMLS CUI [1]
C3146290
Previous Pregnancy Information
Description

Previous Pregnancy Information

Alias
UMLS CUI-1
C0032961
UMLS CUI-2
C1332051
Number of Pregnancies
Description

Patient Pregnancy Count

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus Property
C25742
UMLS CUI [1]
C0422807
Number of live births
Description

Pregnancy Live Birth Count

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25463
UMLS CUI [1,1]
C0481667
UMLS CUI [1,2]
C0449788
Number of Spontaneous abortions
Description

Number of Spontaneous abortions

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus Property
C25742
UMLS CUI [1,1]
C0000786
UMLS CUI [1,2]
C0449788
Number of Elective abortions
Description

Number of Elective abortions

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus Property
C25742
UMLS CUI [1,1]
C0269439
UMLS CUI [1,2]
C0449788
Did the participant experience complications with a previous pregnancy
Description

PersonPreviousPregnancyComplicationInd-3

Data type

integer

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C25627
NCI Thesaurus Property-2
C34941
UMLS CUI [1,1]
C0009566
UMLS CUI [1,2]
C0032961
Specify
Description

PersonPreviousPregnancyComplicationSpecify (If yes)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25627
NCI Thesaurus Property-2
C34941
UMLS CUI [1,1]
C0009566
UMLS CUI [1,2]
C0032961
Were there any congenital anomalies with previous pregnancies
Description

PersonCongenitalAbnormalityPregnancyInd-3

Data type

integer

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C25742
NCI Thesaurus Property-2
C2849
UMLS CUI [1,1]
C0000768
UMLS CUI [1,2]
C0032961
Specify
Description

Patient Congenital Abnormality Specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C2849
UMLS CUI [1,1]
C0000768
UMLS CUI [1,2]
C0032961
Relevant Medical History
Description

Relevant Medical History

Alias
UMLS CUI-1
C0262926
Specify relevant medical history of the mother
Description

PersonPersonalMedicalHistoryPregnancyText (include alcohol/tobacco and substance abuse, illness during this pregnancy, assisted conception; specify other disorders including familial birth defects/genetic/chromosomal disorders/methods of diagnosis, etc)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25742
NCI Thesaurus Property-2
C18772
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0026591
Is the father known
Description

PersonFatherKnownIndicator

Data type

integer

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ValueDomain
C25180
NCI Thesaurus Property
C25174
NCI Thesaurus Property-2
C80137
UMLS CUI [1,1]
C0015671
UMLS CUI [1,2]
C0205309
Number of children father has
Description

FatherPersonChildCount

Data type

integer

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C25174
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus Property
C42708
UMLS CUI [1,1]
C0015671
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0680063
Father's Age
Description

FatherAgeValue

Data type

integer

Measurement units
  • years
Alias
NCI Thesaurus ObjectClass
C25174
NCI Thesaurus Property
C25150
NCI Thesaurus ValueDomain
C25712
UMLS CUI [1,1]
C0015671
UMLS CUI [1,2]
C0001779
years
Specify relevant medical history of the father
Description

ConcomitantDiseaseOrganSystemPersonalMedicalHistorySpecify (include chronic illnesses; specify familial birth defects/genetic/chromosomal disorders, habitual exposure; specify alcohol/tobacco and substance exposure; specify substance abuse and medication use)

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
NCI Thesaurus ObjectClass-2
C25730
NCI Thesaurus Property
C18772
NCI Thesaurus Property-2
C12919
NCI Thesaurus ValueDomain
C25685
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0015671
Comments
Description

Comments

Alias
UMLS CUI-1
C0947611
UMLS CUI-2
C0032961
UMLS CUI-4
C1332051
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C0032961
UMLS CUI [2]
C1332051
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Similar models

For date fields, if the month and year are known, but the exact date is not, please enter "15" for the day.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header - Pregnancy Report Form
C1320722 (UMLS CUI-1)
C0032961 (UMLS CUI-2)
C1332051 (UMLS CUI-3)
Sequence number
Item
Sequence number
integer
C19464 (NCI Thesaurus ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C49153 (NCI Thesaurus ObjectClass-2)
C25694 (NCI Thesaurus Property)
C2348184 (UMLS CUI [1])
Item Group
Current Pregnancy Information
C0032961 (UMLS CUI-1)
C1332051 (UMLS CUI-2)
Patient Most Recent Pregnancy Test Date
Item
Date of pregnancy test
date
C25164 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0032976 (NCI Metathesaurus Property)
C25577 (NCI Thesaurus Property)
C0032976 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Type of pregnancy test
integer
C25284 (NCI Thesaurus ValueDomain)
C38000 (NCI Thesaurus Property)
C25742 (NCI Thesaurus ObjectClass)
C25294 (NCI Thesaurus ObjectClass-2)
C0032976 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
CL.1
Code List
Type of pregnancy test
CL Item
Home Urine Test (1)
CL Item
Clinic Urine Test (2)
CL Item
Serum Test (3)
Item
If a urine test was used to make the initial diagnosis, was the diagnosis confirmed by a serum test
integer
C38148 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C13325 (NCI Thesaurus Property)
C92949 (NCI Thesaurus Property-2)
C0430060 (UMLS CUI [1])
CL.2
Code List
If a urine test was used to make the initial diagnosis, was the diagnosis confirmed by a serum test
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
PatientSerumPregnancyTestDate
Item
Serum pregnancy test date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C13325 (NCI Thesaurus Property)
C0229671 (UMLS 2011AA Property)
C92949 (NCI Thesaurus Property-2)
Date of last menstrual period
Item
Date of last menstrual period
date
C25164 (NCI Thesaurus ValueDomain)
C25551 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C16838 (NCI Thesaurus ObjectClass-2)
C0425932 (UMLS CUI [1])
Estimated date of conception
Item
Estimated date of conception
date
C25164 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25498 (NCI Thesaurus Property)
C16465 (NCI Thesaurus Property-2)
C0009637 (UMLS CUI [1,1])
C0750572 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Pregnancy Delivery Date
Item
Due Date
date
C25164 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus ObjectClass)
C61560 (NCI Thesaurus Property)
C3146290 (UMLS CUI [1])
Item Group
Previous Pregnancy Information
C0032961 (UMLS CUI-1)
C1332051 (UMLS CUI-2)
Patient Pregnancy Count
Item
Number of Pregnancies
integer
C16960 (NCI Thesaurus ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus Property)
C0422807 (UMLS CUI [1])
Pregnancy Live Birth Count
Item
Number of live births
integer
C25463 (NCI Thesaurus ValueDomain)
C0481667 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Number of Spontaneous abortions
Item
Number of Spontaneous abortions
integer
C16960 (NCI Thesaurus ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus Property)
C0000786 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Number of Elective abortions
Item
Number of Elective abortions
integer
C16960 (NCI Thesaurus ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus Property)
C0269439 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Item
Did the participant experience complications with a previous pregnancy
integer
C25190 (NCI Thesaurus ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C25627 (NCI Thesaurus Property)
C34941 (NCI Thesaurus Property-2)
C0009566 (UMLS CUI [1,1])
C0032961 (UMLS CUI [1,2])
CL.2
Code List
Did the participant experience complications with a previous pregnancy
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Specify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C25627 (NCI Thesaurus Property)
C34941 (NCI Thesaurus Property-2)
C0009566 (UMLS CUI [1,1])
C0032961 (UMLS CUI [1,2])
Item
Were there any congenital anomalies with previous pregnancies
integer
C25190 (NCI Thesaurus ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C25742 (NCI Thesaurus Property)
C2849 (NCI Thesaurus Property-2)
C0000768 (UMLS CUI [1,1])
C0032961 (UMLS CUI [1,2])
CL.2
Code List
Were there any congenital anomalies with previous pregnancies
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Patient Congenital Abnormality Specify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C2849 (NCI Thesaurus Property)
C0000768 (UMLS CUI [1,1])
C0032961 (UMLS CUI [1,2])
Item Group
Relevant Medical History
C0262926 (UMLS CUI-1)
relevant medical history of the mother
Item
Specify relevant medical history of the mother
text
C25704 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C25742 (NCI Thesaurus Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS CUI [1,1])
C0026591 (UMLS CUI [1,2])
Item
Is the father known
integer
C25190 (NCI Thesaurus ObjectClass)
C25180 (NCI Thesaurus ValueDomain)
C25174 (NCI Thesaurus Property)
C80137 (NCI Thesaurus Property-2)
C0015671 (UMLS CUI [1,1])
C0205309 (UMLS CUI [1,2])
CL.2
Code List
Is the father known
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
children father has
Item
Number of children father has
integer
C25190 (NCI Thesaurus ObjectClass)
C25174 (NCI Thesaurus ObjectClass-2)
C25463 (NCI Thesaurus ValueDomain)
C42708 (NCI Thesaurus Property)
C0015671 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0680063 (UMLS CUI [1,3])
FatherAgeValue
Item
Father's Age
integer
C25174 (NCI Thesaurus ObjectClass)
C25150 (NCI Thesaurus Property)
C25712 (NCI Thesaurus ValueDomain)
C0015671 (UMLS CUI [1,1])
C0001779 (UMLS CUI [1,2])
relevant medical history of the father
Item
Specify relevant medical history of the father
text
C2991 (NCI Thesaurus ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C18772 (NCI Thesaurus Property)
C12919 (NCI Thesaurus Property-2)
C25685 (NCI Thesaurus ValueDomain)
C0262926 (UMLS CUI [1,1])
C0015671 (UMLS CUI [1,2])
Item Group
Comments
C0947611 (UMLS CUI-1)
C0032961 (UMLS CUI-2)
C1332051 (UMLS CUI-4)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1,1])
C0032961 (UMLS CUI [1,2])
C1332051 (UMLS CUI [2])
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