"B" Symptoms
Item
Does the patient currently have evidence of "B" symptoms?
boolean
C1706867 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Item
If yes, please check current "B" symptoms
integer
C1706867 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Code List
If yes, please check current "B" symptoms
CL Item
Intermittent fevers (2)
Date of physical examination
Item
Date of physical examination
date
C2826643 (UMLS CUI [1])
Height
Item
Height
integer
C0005890 (UMLS CUI [1])
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Karnofsky Status
Item
Karnofsky Status
integer
C0206065 (UMLS CUI [1])
Respirations
Item
Respirations
integer
C0035203 (UMLS CUI [1])
Blood Pressure
Item
Blood Pressure
integer
C0005823 (UMLS CUI [1])
Pulse
Item
Pulse
integer
C0232117 (UMLS CUI [1])
Temperature
Item
Temperature
float
C0005903 (UMLS CUI [1])
Item
Organ system
integer
C0678852 (UMLS CUI [1])
CL Item
1. General Appearance (1)
CL Item
5. Lymph Nodes (5)
CL Item
8. Neurological (8)
CL Item
9. Genitourinary (9)
CL Item
11. Musculoskeletal (11)
Item
Examination finding
integer
C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Code List
Examination finding
If abnormal, specify:
Item
If abnormal, specify:
text
C2826279 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Hematology Date
Item
Hematology Date
date
C0474523 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Lab # (Worksheet B)
Item
Lab # (Worksheet B)
integer
C0022877 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Item
Hematologic tests
integer
C0018941 (UMLS CUI [1])
Code List
Hematologic tests
CL Item
Neutrophils (sears + bands) (6)
CL Item
Other differential (11)
CL Item
ANC (10³/mm³) (12)
Hematologic test results
Item
Hematologic test results
float
C1254595 (UMLS CUI [1,1])
C0205488 (UMLS CUI [1,2])
Chemistry Date
Item
Chemistry Date
date
C0011008 (UMLS CUI [1,1])
C0200345 (UMLS CUI [1,2])
C0008000 (UMLS CUI [1,3])
Lab # (Worksheet B)
Item
Lab # (Worksheet B)
integer
C0022877 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Item
Chemistry tests
integer
C0008000 (UMLS CUI [1,1])
C0022885 (UMLS CUI [1,2])
Code List
Chemistry tests
CL Item
Alkaline Phosphatase (7)
CL Item
Total Bilirubin (9)
Chemistry test results
Item
Chemistry test results
float
C1254595 (UMLS CUI [1,1])
C0005774 (UMLS CUI [1,2])
Item
Anatomic site
integer
C1515974 (UMLS CUI [1,1])
C0011923 (UMLS CUI [1,2])
Not done
Item
Not done?
boolean
C0011923 (UMLS CUI [1,1])
C1272696 (UMLS CUI [1,2])
Date
Item
Date
date
C0011923 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Radiological Imaging Method
integer
C0011923 (UMLS CUI [1,1])
C1275506 (UMLS CUI [1,2])
Code List
Radiological Imaging Method
Other Imaging
Item
Specify other Imaging:
text
C0011923 (UMLS CUI [1,1])
C0079595 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item
Imaging Findings
integer
C0011923 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Code List
Imaging Findings
Abnormal Finding
Item
Specify Abnormal Finding
text
C2826279 (UMLS CUI [1,1])
C0011923 (UMLS CUI [1,2])
Date of biopsy
Item
Date of biopsy
date
C0011008 (UMLS CUI [1,1])
C0005954 (UMLS CUI [1,2])
Item
Marrow cellularity
integer
C1561532 (UMLS CUI [1])
Code List
Marrow cellularity
CL Item
1 Hypercellular (2)
CL Item
2 Hypocellular (3)
Tumor involvement
Item
Tumor involvement
integer
C1517677 (UMLS CUI [1])
Item
Side
integer
C0441987 (UMLS CUI [1,1])
C0475445 (UMLS CUI [1,2])
Item
Bone Marrow Biopsie not done/indicated?
integer
C0005957 (UMLS CUI [1,1])
C1272696 (UMLS CUI [1,2])
Code List
Bone Marrow Biopsie not done/indicated?
CL Item
Not indicated (BM not positive at baseline) (2)
CL Item
Not indicated (patient not in CR} (3)
Item
Since the last response evaluation, has the patient received:
integer
C2347852 (UMLS CUI [1])
Code List
Since the last response evaluation, has the patient received:
CL Item
Platelet transfusion (2)
CL Item
RBC transfusion (3)
CL Item
Erythropoietin (4)
Site
Item
Site
text
C1515974 (UMLS CUI [1])
Method of Determination
Item
Method of Determination
text
C2911685 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1,1])
C1148554 (UMLS CUI [1,2])
Tumor Measurements
Item
Tumor Measurements
integer
C0205485 (UMLS CUI [1,1])
C0242485 (UMLS CUI [1,2])
C1300072 (UMLS CUI [1,3])
Site
Item
Site
text
C1515974 (UMLS CUI [1])
Method of Determination
Item
Method of Determination
text
C2911685 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1,1])
C1148554 (UMLS CUI [1,2])
Item
Status of Non-Measurable Disease
text
C0449438 (UMLS CUI [1,1])
C1334988 (UMLS CUI [1,2])
Code List
Status of Non-Measurable Disease
Item
Response (check one)
integer
C0521982 (UMLS CUI [1])
Code List
Response (check one)
Date of Response Evaluation
Item
Date of Response Evaluation
date
C1704632 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0220825 (UMLS CUI [1,3])
Comments
Item
Comments
text
C0947611 (UMLS CUI [1])
Signature of Investigator
Item
Signature of Investigator
text
C2346576 (UMLS CUI [1])
Date
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])