ID

2670

Beschreibung

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

Stichworte

19.09.12 19.09.12 -
09.01.15 09.01.15 - Martin Dugas

Hochgeladen am

19. September 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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

Modell
Details

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 Formulare

StudyEvent: CALGB 90203: The Expanded Prostate Cancer Index Composite Survey Instrument
1. 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...

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

Header Module

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)

DataAmendedInd-3

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)

Interviewer Module

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)

Quality of Life Module

Item Group

Quality Of Life Module

ProstateQualityofLifeUrinaryLeakageSymptomScale

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)

ProstateQualityofLifeUrinaryControlSymptomScale

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)

ProstateQualityofLifeAdultUndergarmentUseScale

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)

ProstateQualityofLifeUrineLeakageProblemType

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)

ProstateQualityofLifeUrinePainProblemType

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)

ProstateQualityofLifeHematuriaProblemType

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)

ProstateQualityofLifeIncompleteUrinationProblemType

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)

ProstateQualityofLifeUrinaryFrequencyProblemType

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)

ProstateQualityofLifeOverallUrinaryProblemType

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)

ProstateQualityofLifeDefecationUrgencyProblemType

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)

ProstateQualityofLifeDefecationFrequencyProblemType

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)

ProstateQualityofLifeAnalIncontinenceProblemType

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)

ProstateQualityofLifeBloodFecesProblemType

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)

ProstateQualityofLifeAbdominalPainProblemType

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)

ProstateQualityofLifeOverallBowelProblemType

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)

ProstateQualityofLifeErectionFunctionScale

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)

ProstateQualityofLifeEjaculationFunctionScale

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)

ProstateQualityofLifeErectionQualityScale

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)

ProstateQualityofLifeErectionFrequencyScale

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)

ProstateQualityofLifeOverallLibidoFunctionScale

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)

ProstateQualityofLifeOverallLibidoProblemType

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)

ProstateQualityofLifeHotFlashesProblemType

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)

ProstateQualityofLifeBreastSwellingProblemType

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)

ProstateQualityofLifeDepressionProblemType

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)

ProstateQualityofLifeFatigueProblemType

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)

ProstateQualityofLifeWeightProblemType

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)

Footer Module

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)

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

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