ID

3036

Beskrivning

ACOSOG-Z4099 Lung Cancer Symptom Scale (LCSS) Form Surgery With or Without Internal Radiation Therapy Compared With Stereotactic Body Radiation Therapy in Treating Patients With High-Risk Stage I Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=990876FE-87A9-F817-E040-BB89AD433C2C

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=990876FE-87A9-F817-E040-BB89AD433C2C

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2021-09-17 2021-09-17 -
Uppladdad den

19 september 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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NCT01336894 Quality of Life - ACOSOG-Z4099 Lung Cancer Symptom Scale (LCSS) Form - 3180568v1.0

Engelsk

Reproduced with permission of LCSS Associates. To be completed by the patient.

1 Formulär  
  1. StudyEvent: ACOSOG-Z4099 Lung Cancer Symptom Scale (LCSS) Form
    1. Reproduced with permission of LCSS Associates. To be completed by the patient.
Header Module
Beskrivning

Header Module

Patient Study ID
Beskrivning

PatientCoordinatingIdentifierNumber

Datatyp

text

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

PatientInitialsName

Datatyp

text

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

FormCompletionDate

Datatyp

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
M.d. Anderson Symptom Inventory (mdasi-bt)
Beskrivning

M.d. Anderson Symptom Inventory (mdasi-bt)

How is your appetite
Beskrivning

PatientAppetiteLossSymptomScale

Datatyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25559
UMLS 2011AA Property
C1517945
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C25152
UMLS 2011AA Property
C0003618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How much fatigue do you have
Beskrivning

PatientFatigueAssessmentSymptomScale

Datatyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C3036
UMLS 2011AA Property
C0015672
How much coughing do you have
Beskrivning

PatientChokingCoughWorstDifficultySymptomScale

Datatyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C37935
UMLS 2011AA ObjectClass
C0010200
NCI Thesaurus ObjectClass
C50494
UMLS 2011AA ObjectClass
C0008301
NCI Thesaurus Property
C25719
UMLS 2011AA Property
C1522166
NCI Thesaurus Property
C62189
UMLS 2011AA Property
C1299586
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How much shortness of breath do you have
Beskrivning

PatientDyspneaAssessmentSymptomScale

Datatyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C2998
UMLS 2011AA Property
C0013404
How much blood do you see in your sputum
Beskrivning

HemoptysisPresentSymptomScale

Datatyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C3094
UMLS 2011AA ObjectClass
C0019079
How much pain do you have
Beskrivning

PatientWorstPainSymptomScale

Datatyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property
C25719
UMLS 2011AA Property
C1522166
How bad are your symptoms from lung cancer
Beskrivning

LungCarcinomaCurrentSymptomScale

Datatyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus ObjectClass
C4878
UMLS 2011AA ObjectClass
C0684249
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
How much has your illness affected your ability to carry out normal activities
Beskrivning

PatientGeneralizedActivityInterferenceSymptomScale

Datatyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C43431
UMLS 2011AA Property
C0441655
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C63764
UMLS 2011AA Property
C0205246
NCI Thesaurus Property
C72886
UMLS 2011AA Property
C2346501
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How would you rate the quality of your life today
Beskrivning

PatientQualityofLifeAssessmentScore

Datatyp

text

Alias
NCI Thesaurus Property
C17047
UMLS 2011AA Property
C0518214
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
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Similar models

Reproduced with permission of LCSS Associates. To be completed by the patient.

1 Formulär
  1. StudyEvent: ACOSOG-Z4099 Lung Cancer Symptom Scale (LCSS) Form
    1. Reproduced with permission of LCSS Associates. To be completed by the patient.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Header Module
PatientCoordinatingIdentifierNumber
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient Initials (L F M)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
FormCompletionDate
Item
Date Completed (dd MMM yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
Item Group
M.d. Anderson Symptom Inventory (mdasi-bt)
Item
How is your appetite
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25559 (NCI Thesaurus Property)
C1517945 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C25152 (NCI Thesaurus Property)
C0003618 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.1
Code List
How is your appetite
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
How much fatigue do you have
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3036 (NCI Thesaurus Property)
C0015672 (UMLS 2011AA Property)
CL.2
Code List
How much fatigue do you have
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
How much coughing do you have
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C37935 (NCI Thesaurus ObjectClass)
C0010200 (UMLS 2011AA ObjectClass)
C50494 (NCI Thesaurus ObjectClass)
C0008301 (UMLS 2011AA ObjectClass)
C25719 (NCI Thesaurus Property)
C1522166 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.3
Code List
How much coughing do you have
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
How much shortness of breath do you have
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C2998 (NCI Thesaurus Property)
C0013404 (UMLS 2011AA Property)
CL.4
Code List
How much shortness of breath do you have
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
How much blood do you see in your sputum
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C3094 (NCI Thesaurus ObjectClass)
C0019079 (UMLS 2011AA ObjectClass)
CL.5
Code List
How much blood do you see in your sputum
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
How much pain do you have
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25719 (NCI Thesaurus Property)
C1522166 (UMLS 2011AA Property)
CL.6
Code List
How much pain do you have
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
How bad are your symptoms from lung cancer
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C4878 (NCI Thesaurus ObjectClass)
C0684249 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL.7
Code List
How bad are your symptoms from lung cancer
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
How much has your illness affected your ability to carry out normal activities
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C43431 (NCI Thesaurus Property)
C0441655 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C63764 (NCI Thesaurus Property)
C0205246 (UMLS 2011AA Property)
C72886 (NCI Thesaurus Property)
C2346501 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.8
Code List
How much has your illness affected your ability to carry out normal activities
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
How would you rate the quality of your life today
text
C17047 (NCI Thesaurus Property)
C0518214 (UMLS 2011AA Property)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.9
Code List
How would you rate the quality of your life today
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
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