ID

2644

Description

ACOSOG-Z4099 Linear Analogue Self Assessment Form Surgery With or Without Internal Radiation Therapy Compared With Stereotactic Body Radiation Therapy in Treating Patients With High-Risk Stage I Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=986A2EC8-D259-882B-E040-BB89AD4356EB

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=986A2EC8-D259-882B-E040-BB89AD4356EB

Keywords

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

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT01336894 Quality of Life - ACOSOG-Z4099 Linear Analogue Self Assessment Form - 3178862v1.0

English

Directions: Please circle the number (0-10) best reflecting your response to the following that describes your feelings during the past week, including today

1 forms  
Header Module
Description

Header Module

Patient Study ID
Description

PatientCoordinatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25462
UMLS 2011AA Property
C0700114
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Initials (L F M)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Date Completed (dd MMM yyyy)
Description

FormCompletionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
Unnamed2
Description

Unnamed2

your overall mental (intellectual) well being?
Description

QualityofLifeOverallPsychologicalHealthAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C16839
UMLS 2011AA Property
C0025353
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
your overall physical well being
Description

QualityofLifeOverallPhysicalAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C25618
UMLS 2011AA Property
C0205485
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
your overall emotional well being?
Description

QualityofLifeOverallEmotionAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C54266
UMLS 2011AA Property
C0013987
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
Your level of social activity
Description

Quality-of-LifeAssessmentPatientSocialActivityScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C62650
UMLS 2011AA Property
C0728831
NCI Thesaurus Property
C43431
UMLS 2011AA Property
C0441655
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
your overall spiritual well being?
Description

QualityofLifeOverallReligionAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C17085
UMLS 2011AA Property
C0035039
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
Your level of support from friends and family
Description

FamilyPatientEmotionalSupportAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C25173
UMLS 2011AA ObjectClass
C0015576
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0600015
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
Your financial concerns
Description

QualityofLifePaymentDifficultyAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C25371
UMLS 2011AA Property
C0680264
NCI Thesaurus Property
C62189
UMLS 2011AA Property
C1299586
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
Your legal concerns (will, advanced directives, etc.)
Description

QualityofLifeLegalConcernAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C54074
UMLS 2011AA Property
C1301860
NCI Thesaurus Property
C79892
UMLS 2011AA Property
C2699424
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
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Similar models

Directions: Please circle the number (0-10) best reflecting your response to the following that describes your feelings during the past week, including today

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
PatientCoordinatingIdentifierNumber
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient Initials (L F M)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
FormCompletionDate
Item
Date Completed (dd MMM yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
Item Group
Unnamed2
Item
your overall mental (intellectual) well being?
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C16839 (NCI Thesaurus Property)
C0025353 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.1
Code List
your overall mental (intellectual) well being?
CL Item
Whole Number (0)
C0919414 (NCI Metathesaurus)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
your overall physical well being
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C25618 (NCI Thesaurus Property)
C0205485 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.2
Code List
your overall physical well being
CL Item
Whole Number (0)
C0919414 (NCI Metathesaurus)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
your overall emotional well being?
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C54266 (NCI Thesaurus Property)
C0013987 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.3
Code List
your overall emotional well being?
CL Item
Whole Number (0)
C0919414 (NCI Metathesaurus)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
Your level of social activity
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C62650 (NCI Thesaurus Property)
C0728831 (UMLS 2011AA Property)
C43431 (NCI Thesaurus Property)
C0441655 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.4
Code List
Your level of social activity
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
your overall spiritual well being?
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C17085 (NCI Thesaurus Property)
C0035039 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.5
Code List
your overall spiritual well being?
CL Item
Whole Number (0)
C0919414 (NCI Metathesaurus)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
Your level of support from friends and family
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25173 (NCI Thesaurus ObjectClass)
C0015576 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0600015 (NCI Metathesaurus Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.6
Code List
Your level of support from friends and family
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Your financial concerns
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25371 (NCI Thesaurus Property)
C0680264 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.7
Code List
Your financial concerns
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Your legal concerns (will, advanced directives, etc.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C54074 (NCI Thesaurus Property)
C1301860 (UMLS 2011AA Property)
C79892 (NCI Thesaurus Property)
C2699424 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.8
Code List
Your legal concerns (will, advanced directives, etc.)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
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