ID

2700

Description

AMC-075 Pregnancy Report Form (PRF) Vorinostat and Combination Chemotherapy With Rituximab in Treating Patients With Previously Untreated HIV-Related Diffuse Large B-Cell Non-Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0F9B852-8D06-8306-E040-BB89AD434EB4

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0F9B852-8D06-8306-E040-BB89AD434EB4

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/29/17 8/29/17 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lymphoma NCT01193842 On-Study - AMC-075 Pregnancy Report Form (PRF) - 3228000v1.0

English

For date fields, if the month and year are known, but the exact date is not, please enter "15" for the day.

1 forms  
Unnamed1
Description

Unnamed1

Sequence number
Description

SequentialFormSubmissionCount

Data type

double

Alias
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus ObjectClass
C49153
UMLS 2011AA ObjectClass
C1705294
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
Current Pregnancy Information
Description

Current Pregnancy Information

Date of pregnancy test (initial mm/dd/yyyy)
Description

PatientMostRecentPregnancyTestDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0032976
NCI Thesaurus Property
C25577
UMLS 2011AA Property
C1513491
Type of pregnancy test
Description

PregnancyLaboratoryProcedurePerformedType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C25742
UMLS 2011AA ObjectClass
C0032961
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
If a urine test was used to make the initial diagnosis, was the diagnosis confirmed by a serum test
Description

PatientSerumPregnancyTestInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C13325
UMLS 2011AA Property
C0229671
NCI Thesaurus Property
C92949
Serum pregnancy test date (If yes mm/dd/yyyy)
Description

PatientSerumPregnancyTestDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C13325
UMLS 2011AA Property
C0229671
NCI Thesaurus Property
C92949
Date of last menstrual period (mm/dd/yyyy)
Description

LastMenstrualCycleOccurrenceDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25551
UMLS 2011AA ObjectClass
C1517741
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ObjectClass
C16838
UMLS 2011AA ObjectClass
C0025329
Estimated date of conception (mm/dd/yyyy)
Description

PatientEstimatedConceptionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25498
UMLS 2011AA Property
C0750572
NCI Thesaurus Property
C16465
UMLS 2011AA Property
C0009637
Due Date (mm/dd/yyyy)
Description

PregnancyDeliveryDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25742
UMLS 2011AA ObjectClass
C0032961
NCI Thesaurus Property
C61560
Previous Pregnancy Information
Description

Previous Pregnancy Information

Number of Pregnancies (Gravida If Gravida >0, complete the following)
Description

PatientPregnancyCount

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25742
UMLS 2011AA Property
C0032961
Number of live births (Para)
Description

PregnancyLiveBirthCount

Data type

double

Alias
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Number of Spontaneous abortions
Description

PatientPregnancySpontaneousAbortionCount

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25742
UMLS 2011AA Property
C0032961
Number of Elective abortions
Description

PatientPregnancyTherapeuticAbortionCount

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25742
UMLS 2011AA Property
C0032961
Unknown
Description

DataUnknownText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C17998
UMLS 2011AA Property
C0439673
Did the participant experience complications with a previous pregnancy
Description

PersonPreviousPregnancyComplicationInd-3

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25627
UMLS 2011AA Property
C0205156
NCI Thesaurus Property
C34941
UMLS 2011AA Property
C0032962
Specify (If yes)
Description

PersonPreviousPregnancyComplicationSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25627
UMLS 2011AA Property
C0205156
NCI Thesaurus Property
C34941
UMLS 2011AA Property
C0032962
Were there any congenital anomalies with previous pregnancies
Description

PersonCongenitalAbnormalityPregnancyInd-3

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25742
UMLS 2011AA Property
C0032961
NCI Thesaurus Property
C2849
UMLS 2011AA Property
C0000768
Specify (If yes)
Description

PatientCongenitalAbnormalitySpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C2849
UMLS 2011AA Property
C0000768
Relevant Medical History
Description

Relevant Medical History

Specify relevant medical history of the mother (include alcohol/tobacco and substance abuse, illness during this pregnancy, assisted conception; specify other disorders including familial birth defects/genetic/chromosomal disorders/methods of diagnosis, etc)
Description

PersonPersonalMedicalHistoryPregnancyText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25742
UMLS 2011AA Property
C0032961
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
Is the father known
Description

PersonFatherKnownIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25174
UMLS 2011AA Property
C0015671
NCI Thesaurus Property
C80137
UMLS 2011AA Property
C0205309
Number of children father has
Description

FatherPersonChildCount

Data type

double

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25174
UMLS 2011AA ObjectClass
C0015671
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C42708
UMLS 2011AA Property
C0680063
Father's Age (in years)
Description

FatherAgeValue

Data type

double

Measurement units
  • year
Alias
NCI Thesaurus ObjectClass
C25174
UMLS 2011AA ObjectClass
C0015671
NCI Thesaurus Property
C25150
UMLS 2011AA Property
C0001779
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
year
Unknown
Description

DataUnknownText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C17998
UMLS 2011AA Property
C0439673
Specify relevant medical history of the father (include chronic illnesses; specify familial birth defects/genetic/chromosomal disorders, habitual exposure; specify alcohol/tobacco and substance exposure; specify substance abuse and medication use)
Description

ConcomitantDiseaseOrganSystemPersonalMedicalHistorySpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C25730
UMLS 2011AA ObjectClass
C0521115
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus Property
C12919
UMLS 2011AA Property
C0460002
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Comments
Description

Comments

Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
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Similar models

For date fields, if the month and year are known, but the exact date is not, please enter "15" for the day.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
SequentialFormSubmissionCount
Item
Sequence number
double
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C49153 (NCI Thesaurus ObjectClass)
C1705294 (UMLS 2011AA ObjectClass)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
Item Group
Current Pregnancy Information
PatientMostRecentPregnancyTestDate
Item
Date of pregnancy test (initial mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0032976 (NCI Metathesaurus Property)
C25577 (NCI Thesaurus Property)
C1513491 (UMLS 2011AA Property)
Item
Type of pregnancy test
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25742 (NCI Thesaurus ObjectClass)
C0032961 (UMLS 2011AA ObjectClass)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
CL.1
Code List
Type of pregnancy test
CL Item
Home Urine Test (Home urine test)
CL Item
Clinic Urine Test (Clinic urine test)
CL Item
Serum Test (Serum test)
Item
If a urine test was used to make the initial diagnosis, was the diagnosis confirmed by a serum test
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C13325 (NCI Thesaurus Property)
C0229671 (UMLS 2011AA Property)
C92949 (NCI Thesaurus Property)
CL.2
Code List
If a urine test was used to make the initial diagnosis, was the diagnosis confirmed by a serum test
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientSerumPregnancyTestDate
Item
Serum pregnancy test date (If yes mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C13325 (NCI Thesaurus Property)
C0229671 (UMLS 2011AA Property)
C92949 (NCI Thesaurus Property)
LastMenstrualCycleOccurrenceDate
Item
Date of last menstrual period (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ObjectClass)
C1517741 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C16838 (NCI Thesaurus ObjectClass)
C0025329 (UMLS 2011AA ObjectClass)
PatientEstimatedConceptionDate
Item
Estimated date of conception (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25498 (NCI Thesaurus Property)
C0750572 (UMLS 2011AA Property)
C16465 (NCI Thesaurus Property)
C0009637 (UMLS 2011AA Property)
PregnancyDeliveryDate
Item
Due Date (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25742 (NCI Thesaurus ObjectClass)
C0032961 (UMLS 2011AA ObjectClass)
C61560 (NCI Thesaurus Property)
Item Group
Previous Pregnancy Information
PatientPregnancyCount
Item
Number of Pregnancies (Gravida If Gravida >0, complete the following)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
PregnancyLiveBirthCount
Item
Number of live births (Para)
double
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
PatientPregnancySpontaneousAbortionCount
Item
Number of Spontaneous abortions
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
PatientPregnancyTherapeuticAbortionCount
Item
Number of Elective abortions
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
DataUnknownText
Item
Unknown
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C17998 (NCI Thesaurus Property)
C0439673 (UMLS 2011AA Property)
Item
Did the participant experience complications with a previous pregnancy
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25627 (NCI Thesaurus Property)
C0205156 (UMLS 2011AA Property)
C34941 (NCI Thesaurus Property)
C0032962 (UMLS 2011AA Property)
CL.3
Code List
Did the participant experience complications with a previous pregnancy
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PersonPreviousPregnancyComplicationSpecify
Item
Specify (If yes)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25627 (NCI Thesaurus Property)
C0205156 (UMLS 2011AA Property)
C34941 (NCI Thesaurus Property)
C0032962 (UMLS 2011AA Property)
Item
Were there any congenital anomalies with previous pregnancies
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
C2849 (NCI Thesaurus Property)
C0000768 (UMLS 2011AA Property)
CL.4
Code List
Were there any congenital anomalies with previous pregnancies
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientCongenitalAbnormalitySpecify
Item
Specify (If yes)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2849 (NCI Thesaurus Property)
C0000768 (UMLS 2011AA Property)
Item Group
Relevant Medical History
PersonPersonalMedicalHistoryPregnancyText
Item
Specify relevant medical history of the mother (include alcohol/tobacco and substance abuse, illness during this pregnancy, assisted conception; specify other disorders including familial birth defects/genetic/chromosomal disorders/methods of diagnosis, etc)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
Item
Is the father known
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25174 (NCI Thesaurus Property)
C0015671 (UMLS 2011AA Property)
C80137 (NCI Thesaurus Property)
C0205309 (UMLS 2011AA Property)
CL.5
Code List
Is the father known
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Participant Declines To Answer (Participant declines to answer)
FatherPersonChildCount
Item
Number of children father has
double
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25174 (NCI Thesaurus ObjectClass)
C0015671 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C42708 (NCI Thesaurus Property)
C0680063 (UMLS 2011AA Property)
FatherAgeValue
Item
Father's Age (in years)
double
C25174 (NCI Thesaurus ObjectClass)
C0015671 (UMLS 2011AA ObjectClass)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS 2011AA Property)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
DataUnknownText
Item
Unknown
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C17998 (NCI Thesaurus Property)
C0439673 (UMLS 2011AA Property)
ConcomitantDiseaseOrganSystemPersonalMedicalHistorySpecify
Item
Specify relevant medical history of the father (include chronic illnesses; specify familial birth defects/genetic/chromosomal disorders, habitual exposure; specify alcohol/tobacco and substance exposure; specify substance abuse and medication use)
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C12919 (NCI Thesaurus Property)
C0460002 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Comments
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
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