ID

26133

Description

AMC-063 FACT/GOG-Neurotoxicity Questionnaire Form (NTQ) Bortezomib in Treating Patients With Relapsed or Refractory AIDS-Related Kaposi Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=816407E2-1423-1A8A-E040-BB89AD433DA9

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=816407E2-1423-1A8A-E040-BB89AD433DA9

Keywords

Versions (1)
  1. 10/9/17 10/9/17 -
Copyright Holder

AIDS Malignancy Consortium

Uploaded on

October 9, 2017

DOI

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License

Creative Commons BY-NC 3.0
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AMC-063 FACT/GOG-Neurotoxicity Questionnaire Form (NTQ)

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-063 FACT/GOG-Neurotoxicity Questionnaire Form (NTQ)
    1. No Instruction available.
Neurotoxicity Questionnaire Form
Description

Neurotoxicity Questionnaire Form

Alias
UMLS CUI-1
C3899177
UMLS CUI-2
C0276535
Visit number
Description

Visit number

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI [1]
C1549755
Neurotoxicity Questionnaire Form
Description

Neurotoxicity Questionnaire Form

Alias
UMLS CUI-1
C3899177
UMLS CUI-2
C0276535
I have numbness or tingling in my hands
Description

NeurotoxicityPatientParaesthesiaHandAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Metathesaurus Property
C0239836
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3829780
I have numbness or tingling in my feet
Description

NeurotoxicityPatientParaesthesiaFootAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Metathesaurus Property
CL108114
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3829781
I feel discomfort in my hands
Description

NeurotoxicityPatientHandDiscomfortAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C32712
NCI Metathesaurus Property
CL047845
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3830164
I feel discomfort in my feet
Description

NeurotoxicityPatientFootDiscomfortAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Metathesaurus Property
CL050515
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3830165
I have joint pain or muscle cramps
Description

NeurotoxicityPatientArthralgiaAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Metathesaurus Property
C0003862
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3829787
I feel weak all over
Description

NeurotoxicityPatientMuscleWeaknessAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Metathesaurus Property
C0151786
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3274923
I have trouble hearing
Description

NeurotoxicityPatientHearingAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C16670
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3829759
I get a ringing or buzzing in my ears
Description

NeurotoxicityPatientTinnitusAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C50772
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3829985
I have trouble buttoning buttons
Description

NeurotoxicityPatientHandCoordinationAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C25462
NCI Thesaurus Property-3
C32712
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3829762
I have trouble feeling the shape of small objects when they are in my hand
Description

NeurotoxicityPatientHypoaesthesiaAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Metathesaurus Property
C0020580
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3829760
I have trouble walking
Description

NeurotoxicityPatientParaparesisAssessmentQualityofLifeScale

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27961
NCI Thesaurus Property
C20989
NCI Metathesaurus Property
C0221166
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ValueDomain-2
C17047
UMLS CUI [1]
C3829756
Comments
Description

Comments

Alias
UMLS CUI-1
C0947611
UMLS CUI-2
C3899177
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]
C3899177
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-063 FACT/GOG-Neurotoxicity Questionnaire Form (NTQ)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Neurotoxicity Questionnaire Form
C3899177 (UMLS CUI-1)
C0276535 (UMLS CUI-2)
Visit number
Item
Visit number
float
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI [1])
Item Group
Neurotoxicity Questionnaire Form
C3899177 (UMLS CUI-1)
C0276535 (UMLS CUI-2)
Item
I have numbness or tingling in my hands
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0239836 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829780 (UMLS CUI [1])
CL.1
Code List
I have numbness or tingling in my hands
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I have numbness or tingling in my feet
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
CL108114 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829781 (UMLS CUI [1])
CL.1
Code List
I have numbness or tingling in my feet
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I feel discomfort in my hands
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C32712 (NCI Thesaurus Property-2)
CL047845 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3830164 (UMLS CUI [1])
CL.1
Code List
I feel discomfort in my hands
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I feel discomfort in my feet
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
CL050515 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3830165 (UMLS CUI [1])
CL.1
Code List
I feel discomfort in my feet
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I have joint pain or muscle cramps
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0003862 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829787 (UMLS CUI [1])
CL.1
Code List
I have joint pain or muscle cramps
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I feel weak all over
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0151786 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3274923 (UMLS CUI [1])
CL.1
Code List
I feel weak all over
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I have trouble hearing
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C16670 (NCI Thesaurus Property-2)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829759 (UMLS CUI [1])
CL.1
Code List
I have trouble hearing
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I get a ringing or buzzing in my ears
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C50772 (NCI Thesaurus Property-2)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829985 (UMLS CUI [1])
CL.1
Code List
I get a ringing or buzzing in my ears
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I have trouble buttoning buttons
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C25462 (NCI Thesaurus Property-2)
C32712 (NCI Thesaurus Property-3)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829762 (UMLS CUI [1])
CL.1
Code List
I have trouble buttoning buttons
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I have trouble feeling the shape of small objects when they are in my hand
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0020580 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829760 (UMLS CUI [1])
CL.1
Code List
I have trouble feeling the shape of small objects when they are in my hand
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item
I have trouble walking
integer
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0221166 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829756 (UMLS CUI [1])
CL.1
Code List
I have trouble walking
CL Item
A Little Bit (1)
CL Item
Not At All (2)
CL Item
Quite A Bit (3)
CL Item
Somewhat (4)
CL Item
Very Much (5)
Item Group
Comments
C0947611 (UMLS CUI-1)
C3899177 (UMLS CUI-2)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1,1])
C3899177 (UMLS CUI [1,2])
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