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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

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

AIDS Malignancy Consortium

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October 9, 2017

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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])
    Back to the top of the page 

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