ID

2670

Description

CALGB 90203: The Expanded Prostate Cancer Index Composite (EPIC) Survey Instrument - Short Form [Form C-1145 v1 10/23/2006] Surgery With or Without Docetaxel and Leuprolide or Goserelin in Treating Patients With High-Risk Localized Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1F9FC2EA-E06D-5BE7-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1F9FC2EA-E06D-5BE7-E044-0003BA3F9857

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

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

NCT00430183 Quality of Life - CALGB 90203: The Expanded Prostate Cancer Index Composite Survey Instrument - 2527357v1.0

English

Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice...

1 forms  
Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
Description

Ccrr Module For Calgb 90202: Prostate Specific Antigen Form

CALGB Form (C-714)
Description

CALGBFormIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25442
UMLS 2011AA ObjectClass
C1516238
CALGB Study No.
Description

ProtocolCALGBIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25442
UMLS 2011AA Property
C1516238
CALGB Patient ID
Description

PatientCALGBIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25442
UMLS 2011AA Property
C1516238
Assessment Date (mm dd yyyy)
Description

PatientAssessmentDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Are data amended
Description

DataAmendedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient Initials (Last, First Middle)
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
Patient Hospital No.
Description

PatientMedicalRecordNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25261
UMLS 2011AA Property
C0205476
NCI Thesaurus Property
C25198
UMLS 2011AA Property
C0034869
Institution/Affiliate
Description

CombinedInstitutionName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS 2011AA ObjectClass
C0205195
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
Participating Group
Description

ParticipatingGroupName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participating Group Study No.
Description

ProtocolParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participating Group Patient ID
Description

PatientParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Interviewer Module
Description

Interviewer Module

Person Completing Form (Recommended Term for CRF Text "Responsible Person Name" Long Name of Recommended CDE, but not Doc Text Interviewer or CRA)
Description

ResponsiblePersonName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Assessment No.
Description

AssessmentIdentifierCount

Data type

double

Alias
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Quality Of Life Module
Description

Quality Of Life Module

Over the past 4 weeks how often have you leaked urine
Description

ProstateQualityofLifeUrinaryLeakageSymptomScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25711
UMLS 2011AA Property
C1524119
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C40416
UMLS 2011AA Property
C0015376
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Which of the following best describes your urinary control during the last 4 weeks
Description

ProstateQualityofLifeUrinaryControlSymptomScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25711
UMLS 2011AA Property
C1524119
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C61299
UMLS 2011AA Property
C2587213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
Description

ProstateQualityofLifeAdultUndergarmentUseScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C17600
UMLS 2011AA Property
C0001675
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
NCI Metathesaurus Property
C0453880
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Select one answer in each line.)
Description

ProstateQualityofLifeUrineLeakageProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C13283
UMLS 2011AA Property
C0042036
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C40416
UMLS 2011AA Property
C0015376
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Pain or burning on urination
Description

ProstateQualityofLifeUrinePainProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property
C13283
UMLS 2011AA Property
C0042036
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Bleeding with urination
Description

ProstateQualityofLifeHematuriaProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C3090
UMLS 2011AA Property
C0018965
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Weak urine stream or incomplete emptying
Description

ProstateQualityofLifeIncompleteUrinationProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C25744
UMLS 2011AA Property
C0042034
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Need to urinate frequently during the day
Description

ProstateQualityofLifeUrinaryFrequencyProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C26906
UMLS 2011AA Property
C0677481
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Select one.)
Description

ProstateQualityofLifeOverallUrinaryProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C25711
UMLS 2011AA Property
C1524119
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Select one answer in each line.)
Description

ProstateQualityofLifeDefecationUrgencyProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C62788
UMLS 2011AA Property
C0426636
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Increased frequency of bowel movements
Description

ProstateQualityofLifeDefecationFrequencyProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C25515
UMLS 2011AA Property
C0439603
NCI Thesaurus Property
C62787
UMLS 2011AA Property
C0011135
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Losing control of your stools
Description

ProstateQualityofLifeAnalIncontinenceProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C43362
UMLS 2011AA Property
C0003461
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Metathesaurus Property
C0021167
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Bloody stools
Description

ProstateQualityofLifeBloodFecesProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C12434
UMLS 2011AA Property
C0229664
NCI Thesaurus Property
C13234
UMLS 2011AA Property
C0015733
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Abdominal/pelvic/rectal pain
Description

ProstateQualityofLifeAbdominalPainProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property
C25342
UMLS 2011AA Property
C0000726
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Select one.)
Description

ProstateQualityofLifeOverallBowelProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C12736
UMLS 2011AA Property
C0021853
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Your ability to have an erection (How would you rate each of the following during the last 4 weeks? Select one answer in each line.)
Description

ProstateQualityofLifeErectionFunctionScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property
C25740
UMLS 2011AA Property
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your ability to reach orgasm (climax)
Description

ProstateQualityofLifeEjaculationFunctionScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property
C16531
UMLS 2011AA Property
C0013746
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How would you describe the usual QUALITY of your erections during the last 4 weeks
Description

ProstateQualityofLifeErectionQualityScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25283
UMLS 2011AA Property
C0332306
NCI Thesaurus Property
C25740
UMLS 2011AA Property
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How would you describe the FREQUENCY of your erections during the last 4 weeks
Description

ProstateQualityofLifeErectionFrequencyScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property
C25740
UMLS 2011AA Property
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Overall, how would you rate your ability to function sexually during the last 4 weeks
Description

ProstateQualityofLifeOverallLibidoFunctionScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property
C37986
UMLS 2011AA Property
C0023618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
Description

ProstateQualityofLifeOverallLibidoProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C37986
UMLS 2011AA Property
C0023618
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Select one answer in each line.)
Description

ProstateQualityofLifeHotFlashesProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C3109
UMLS 2011AA Property
C0600142
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Breast tenderness/enlargement
Description

ProstateQualityofLifeBreastSwellingProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C3399
UMLS 2011AA Property
C0038999
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Feeling depressed
Description

ProstateQualityofLifeDepressionProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C2982
UMLS 2011AA Property
C0011570
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Lack of energy
Description

ProstateQualityofLifeFatigueProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C3036
UMLS 2011AA Property
C0015672
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Change in body weight
Description

ProstateQualityofLifeWeightProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus Property
C25208
UMLS 2011AA Property
C0043100
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
Description

Ccrr Module For Calgb 90202: Prostate Specific Antigen Form

Completed by (Last name, First Name)
Description

ResponsiblePersonSignatureText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Date Form Completed (mm dd yyyy)
Description

FormCompleteDate

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
NCI Thesaurus ValueDomain
C25367
Back to the top of the page

Similar models

Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice...

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
CALGBFormIdentifierNumber
Item
CALGB Form (C-714)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus ObjectClass)
C1516238 (UMLS 2011AA ObjectClass)
ProtocolCALGBIdentifierNumber
Item
CALGB Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus Property)
C1516238 (UMLS 2011AA Property)
PatientCALGBIdentifierNumber
Item
CALGB Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus Property)
C1516238 (UMLS 2011AA Property)
PatientAssessmentDate
Item
Assessment Date (mm dd yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
Item
Are data amended
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PatientInitialsName
Item
Patient Initials (Last, First Middle)
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)
PatientMedicalRecordNumber
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25198 (NCI Thesaurus Property)
C0034869 (UMLS 2011AA Property)
CombinedInstitutionName
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
ParticipatingGroupName
Item
Participating Group
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProtocolParticipatingIdentifierNumber
Item
Participating Group Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientParticipatingIdentifierNumber
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Interviewer Module
ResponsiblePersonName
Item
Person Completing Form (Recommended Term for CRF Text "Responsible Person Name" Long Name of Recommended CDE, but not Doc Text Interviewer or CRA)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
AssessmentIdentifierCount
Item
Assessment No.
double
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item Group
Quality Of Life Module
Item
Over the past 4 weeks how often have you leaked urine
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25711 (NCI Thesaurus Property)
C1524119 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C40416 (NCI Thesaurus Property)
C0015376 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.2
Code List
Over the past 4 weeks how often have you leaked urine
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
Item
Which of the following best describes your urinary control during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25711 (NCI Thesaurus Property)
C1524119 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C61299 (NCI Thesaurus Property)
C2587213 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.3
Code List
Which of the following best describes your urinary control during the last 4 weeks
CL Item
No Urinary Control (No urinary control whatsoever)
CL Item
Frequent Dribbling (Frequent dribbling)
CL Item
Occasional Dribbling (Occasional dribbling)
CL Item
Normal Urinary Control (Total control)
Item
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C17600 (NCI Thesaurus Property)
C0001675 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C0453880 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.4
Code List
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
CL Item
None (No pads)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 Per Day (1 pad per day)
CL Item
2 Per Day (2 pads per day)
CL Item
3+ Per Day (3 or more pads per day)
Item
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Select one answer in each line.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C13283 (NCI Thesaurus Property)
C0042036 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C40416 (NCI Thesaurus Property)
C0015376 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.5
Code List
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Select one answer in each line.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Pain or burning on urination
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C13283 (NCI Thesaurus Property)
C0042036 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
Pain or burning on urination
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Bleeding with urination
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C3090 (NCI Thesaurus Property)
C0018965 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.7
Code List
Bleeding with urination
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Weak urine stream or incomplete emptying
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25744 (NCI Thesaurus Property)
C0042034 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.8
Code List
Weak urine stream or incomplete emptying
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Need to urinate frequently during the day
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C26906 (NCI Thesaurus Property)
C0677481 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.9
Code List
Need to urinate frequently during the day
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Select one.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25711 (NCI Thesaurus Property)
C1524119 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.10
Code List
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Select one.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Select one answer in each line.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C62788 (NCI Thesaurus Property)
C0426636 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.11
Code List
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Select one answer in each line.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Increased frequency of bowel movements
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25515 (NCI Thesaurus Property)
C0439603 (UMLS 2011AA Property)
C62787 (NCI Thesaurus Property)
C0011135 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.12
Code List
Increased frequency of bowel movements
CL Item
Severe Problem (Big problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
Item
Losing control of your stools
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C43362 (NCI Thesaurus Property)
C0003461 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C0021167 (NCI Metathesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.13
Code List
Losing control of your stools
CL Item
Severe Problem (Big problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
Item
Bloody stools
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C12434 (NCI Thesaurus Property)
C0229664 (UMLS 2011AA Property)
C13234 (NCI Thesaurus Property)
C0015733 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.14
Code List
Bloody stools
CL Item
Severe Problem (Big problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
Item
Abdominal/pelvic/rectal pain
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25342 (NCI Thesaurus Property)
C0000726 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.15
Code List
Abdominal/pelvic/rectal pain
CL Item
Severe Problem (Big problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
Item
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Select one.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C12736 (NCI Thesaurus Property)
C0021853 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.16
Code List
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Select one.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Your ability to have an erection (How would you rate each of the following during the last 4 weeks? Select one answer in each line.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property)
C0030847 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.17
Code List
Your ability to have an erection (How would you rate each of the following during the last 4 weeks? Select one answer in each line.)
CL Item
None (Very poor to None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
Your ability to reach orgasm (climax)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C16531 (NCI Thesaurus Property)
C0013746 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.18
Code List
Your ability to reach orgasm (climax)
CL Item
None (Very poor to None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
How would you describe the usual QUALITY of your erections during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25283 (NCI Thesaurus Property)
C0332306 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property)
C0030847 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.19
Code List
How would you describe the usual QUALITY of your erections during the last 4 weeks
CL Item
None (None at all)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Not Firm Enough For Any Sexual Activity (Not firm enough for any sexual activity)
CL Item
Firm Enough For Masturbation And Foreplay Only (Firm enough for masturbation and foreplay only)
CL Item
Firm Enough For Intercourse (Firm enough for intercourse)
Item
How would you describe the FREQUENCY of your erections during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property)
C0030847 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.20
Code List
How would you describe the FREQUENCY of your erections during the last 4 weeks
CL Item
Never (I NEVER had an erection when I wanted one)
CL Item
Less Than Half (I had an erection LESS THAN HALF the time I wanted one)
CL Item
About Half (approximately 50%) (I had an erection ABOUT HALF the time I wanted one)
CL Item
More Than Half (I had an erection MORE THAN HALF the time I wanted one)
CL Item
Normal (I had an erection WHENEVER I wanted one)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
Item
Overall, how would you rate your ability to function sexually during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C37986 (NCI Thesaurus Property)
C0023618 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.21
Code List
Overall, how would you rate your ability to function sexually during the last 4 weeks
CL Item
Very Poor (Very poor)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C37986 (NCI Thesaurus Property)
C0023618 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.22
Code List
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Select one answer in each line.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C3109 (NCI Thesaurus Property)
C0600142 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.23
Code List
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Select one answer in each line.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Breast tenderness/enlargement
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C3399 (NCI Thesaurus Property)
C0038999 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.24
Code List
Breast tenderness/enlargement
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Feeling depressed
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C2982 (NCI Thesaurus Property)
C0011570 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.25
Code List
Feeling depressed
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Lack of energy
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C3036 (NCI Thesaurus Property)
C0015672 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.26
Code List
Lack of energy
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Change in body weight
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C25208 (NCI Thesaurus Property)
C0043100 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.27
Code List
Change in body weight
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item Group
Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
ResponsiblePersonSignatureText
Item
Completed by (Last name, First Name)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
FormCompleteDate
Item
Date Form Completed (mm dd 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)
C25367 (NCI Thesaurus ValueDomain)
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial