ID

3427

Description

RTOG-0924 QL: PSQI/GLTEQ Form Androgen-Deprivation Therapy and Radiation Therapy in Treating Patients With Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D869ED1-F271-8812-E040-BB89AD432EA8

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D869ED1-F271-8812-E040-BB89AD432EA8

Keywords

Versions (3)
  1. 9/20/12 9/20/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

September 20, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer NCT01368588 Quality of Life - RTOG-0924 QL: PSQI/GLTEQ Form - 3196710v1.0

English

INSTRUCTIONS: This page must be completed by the medical staff( nurse, data manager, physician, etc.) Questionnaires for all time points are required even if submission time points deviate from the specified intervals. Only patient death or documented patient refusal will be an acceptable reason for omission of the QOL questionnaires. However, this page must be completed and submitted for every time point on the calendar regardless of whether the QOL questionnaire was completed. Every effort possible should be made to collect the data on time

1 forms  
Unnamed Module 1
Description

Unnamed Module 1

RTOG Study No.
Description

ProtocolRTOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Case #
Description

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C19778
UMLS 2011AA ObjectClass
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C49152
UMLS 2011AA Property
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Description

InstitutionName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution No.
Description

InstitutionIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Initials
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
RTOG Patient ID
Description

PatientRadiationTherapyOncologyGroupIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Amended data
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
Unamed Module 2
Description

Unamed Module 2

Time point
Description

AssessmentPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Other specify
Description

AssessmentPeriodSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Did the patient complete any items on the questionnaire?
Description

PatientQuestionnaireCompleteInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
Date Questionnaire Completed
Description

QualityofLifeCompleteAssessmentDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25367
Reason Questionnaire was not Completed
Description

PatientIncompleteQuestionnaireReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
Patient refused for other reason, specify
Description

PatientRefuseIncompleteQuestionnaireSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C49161
UMLS 2011AA Property
C1705116
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Other reason, specify
Description

PatientIncompleteQuestionnaireOtherSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C17649
UMLS 2011AA ValueDomain
C0205394
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
Did the patient require any assistance in completing the questionnaire?
Description

PatientQuestionnaireAssistanceInd

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
Extent of assistance given
Description

PatientQuestionnaireAssistanceType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
Combination of above, specify
Description

PatientQuestionnaireAssistanceCombinedSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C25454
UMLS 2011AA ValueDomain
C0205195
Other, specify
Description

PatientQuestionnaireAssistanceOtherSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C17649
UMLS 2011AA ValueDomain
C0205394
Specify the person who assisted the patient
Description

PatientQuestionnaireAssistancePersonCategory

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25190
UMLS 2011AA ValueDomain
C0027361
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
Specify method of completion
Description

PatientQuestionnaireCompleteMethodofCollectionType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
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
Signature of Person Completing This Form
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 Originally Completed
Description

FormOriginalCompleteDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25604
UMLS 2011AA Property
C0205313
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
Exercise
Description

Exercise

Times per week (Mild exercise - that is, minimal effort exercise that did not make you perspire, such as easy walking, yoga, bowling, lawn bowling, shuffleboard, or golf)
Description

QualityofLifeMildExercisePerformedAssessmentWeekFrequency

Data type

double

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property
C70666
UMLS 2011AA Property
C2945599
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C16567
UMLS 2011AA Property
C0015259
NCI Thesaurus ValueDomain
C29844
UMLS 2011AA ValueDomain
C0439230
NCI Thesaurus ValueDomain
C25515
UMLS 2011AA ValueDomain
C0439603
Average duration (Mild exercise - that is, minimal effort exercise that did not make you perspire, such as easy walking, yoga, bowling, lawn bowling, shuffleboard, or golf mins.)
Description

QualityofLifeMildExercisePerformedAssessmentDuration

Data type

double

Measurement units
  • min
Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property
C70666
UMLS 2011AA Property
C2945599
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C16567
UMLS 2011AA Property
C0015259
NCI Thesaurus ValueDomain
C25330
UMLS 2011AA ValueDomain
C0449238
min
Times per week (Moderate exercise - that is, exercise that is not exhausting and which made you perspire lightly, such as fast walking, tennis, easy bicycling, easy swimming, or popular and folk dancing)
Description

QualityofLifeModerateExercisePerformedAssessmentWeekFrequency

Data type

double

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C61376
UMLS 2011AA Property
C1881878
NCI Thesaurus Property
C16567
UMLS 2011AA Property
C0015259
NCI Thesaurus ValueDomain
C29844
UMLS 2011AA ValueDomain
C0439230
NCI Thesaurus ValueDomain
C25515
UMLS 2011AA ValueDomain
C0439603
Average duration (Moderate exercise - that is, exercise that is not exhausting and which made you perspire lightly, such as fast walking, tennis, easy bicycling, easy swimming, or popular and folk dancing mins.)
Description

QualityofLifeModerateExercisePerformedAssessmentDuration

Data type

double

Measurement units
  • min
Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C61376
UMLS 2011AA Property
C1881878
NCI Thesaurus Property
C16567
UMLS 2011AA Property
C0015259
NCI Thesaurus ValueDomain
C25330
UMLS 2011AA ValueDomain
C0449238
min
Times per week (Strenuous exercise - that is, exercise that made your heart beat rapidly and made you sweat, such as running, aerobics classes, cross country skiing, vigorous swimming, or vigorous bicycling)
Description

QualityofLifeHighExercisePerformedAssessmentWeekFrequency

Data type

double

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C25227
UMLS 2011AA Property
C0205250
NCI Thesaurus Property
C16567
UMLS 2011AA Property
C0015259
NCI Thesaurus ValueDomain
C29844
UMLS 2011AA ValueDomain
C0439230
NCI Thesaurus ValueDomain
C25515
UMLS 2011AA ValueDomain
C0439603
Average duration (Strenuous exercise - that is, exercise that made your heart beat rapidly and made you sweat, such as running, aerobics classes, cross country skiing, vigorous swimming, or vigorous bicycling mins.)
Description

QualityofLifeHighExercisePerformedAssessmentDuration

Data type

double

Measurement units
  • min
Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C25227
UMLS 2011AA Property
C0205250
NCI Thesaurus Property
C16567
UMLS 2011AA Property
C0015259
NCI Thesaurus ValueDomain
C25330
UMLS 2011AA ValueDomain
C0449238
min
I have been experiencing generalized muscle weakness over the last week
Description

QualityofLifeMuscleWeaknessAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property
C50658
UMLS 2011AA Property
C0151786
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
During the past month, how would you rate your sleep quality overall
Description

QualityofLifeSleepQualityAssessmentScore

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property
C73425
UMLS 2011AA Property
C0037313
NCI Thesaurus Property
C25283
UMLS 2011AA Property
C0332306
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
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INSTRUCTIONS: This page must be completed by the medical staff( nurse, data manager, physician, etc.) Questionnaires for all time points are required even if submission time points deviate from the specified intervals. Only patient death or documented patient refusal will be an acceptable reason for omission of the QOL questionnaires. However, this page must be completed and submitted for every time point on the calendar regardless of whether the QOL questionnaire was completed. Every effort possible should be made to collect the data on time

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed Module 1
ProtocolRTOGIdentifierNumber
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass)
C1514695 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property)
C1706256 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InstitutionIdentifierNumber
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient Initials
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)
PatientRadiationTherapyOncologyGroupIdentifierNumber
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Amended data
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
Amended data
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unamed Module 2
Item
Time point
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.2
Code List
Time point
CL Item
Baseline (baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
CL Item
Last Week Of Radiation Therapy (Last week of RT)
CL Item
3 Months After Rt (3 months after RT)
CL Item
6 Months Of Radiation Therapy (6 months after RT)
CL Item
12 Months After Radiation Therapy (12 months after RT)
CL Item
60 Months After Radiation Therapy (60 months after RT)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
AssessmentPeriodSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
Item
Did the patient complete any items on the questionnaire?
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
CL.3
Code List
Did the patient complete any items on the questionnaire?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
Item
Reason Questionnaire was not Completed
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
CL.4
Code List
Reason Questionnaire was not Completed
CL Item
Not Applicable, Questionnaire Was Completed (Not applicable, questionnaire was completed)
CL Item
Patient Refused Due To Illness (Patient refused due to illness)
CL Item
Patient Refused For Other Reason (Patient refused for other reason)
CL Item
Patient Unable To Be Contacted (Patient unable to be contacted)
CL Item
Institution Error (Institutional error)
CL Item
Tool Not Availalble In Patient's Language (Tool not available in patient's language)
CL Item
Other Reason (Other reason)
PatientRefuseIncompleteQuestionnaireSpecify
Item
Patient refused for other reason, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C49161 (NCI Thesaurus Property)
C1705116 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
PatientIncompleteQuestionnaireOtherSpecify
Item
Other reason, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain)
C0205394 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
Item
Did the patient require any assistance in completing the questionnaire?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
CL.5
Code List
Did the patient require any assistance in completing the questionnaire?
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown If Assistance Given (Unknown if assistance given)
Item
Extent of assistance given
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
CL.6
Code List
Extent of assistance given
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Read Items To Patient (Read items to patient)
CL Item
Interpreted Items For Patient (Interpreted items for patient)
CL Item
Marked Items Per Patient's Response (Marked items per patient's response)
CL Item
Combination Of Above (Combination of above)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientQuestionnaireAssistanceCombinedSpecify
Item
Combination of above, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25454 (NCI Thesaurus ValueDomain)
C0205195 (UMLS 2011AA ValueDomain)
PatientQuestionnaireAssistanceOtherSpecify
Item
Other, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain)
C0205394 (UMLS 2011AA ValueDomain)
Item
Specify the person who assisted the patient
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25190 (NCI Thesaurus ValueDomain)
C0027361 (UMLS 2011AA ValueDomain)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
CL.7
Code List
Specify the person who assisted the patient
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Staff Member (Staff member)
CL Item
Family (Family)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
Item
Specify method of completion
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
CL.8
Code List
Specify method of completion
CL Item
At Appointment (At appointment)
CL Item
By Mail (By mail)
CL Item
By Telephone (By telephone)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
ResponsiblePersonSignatureText
Item
Signature of Person Completing This Form
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)
FormOriginalCompleteDate
Item
Date Form Originally Completed
date
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
Item Group
Exercise
QualityofLifeMildExercisePerformedAssessmentWeekFrequency
Item
Times per week (Mild exercise - that is, minimal effort exercise that did not make you perspire, such as easy walking, yoga, bowling, lawn bowling, shuffleboard, or golf)
double
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C70666 (NCI Thesaurus Property)
C2945599 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C16567 (NCI Thesaurus Property)
C0015259 (UMLS 2011AA Property)
C29844 (NCI Thesaurus ValueDomain)
C0439230 (UMLS 2011AA ValueDomain)
C25515 (NCI Thesaurus ValueDomain)
C0439603 (UMLS 2011AA ValueDomain)
QualityofLifeMildExercisePerformedAssessmentDuration
Item
Average duration (Mild exercise - that is, minimal effort exercise that did not make you perspire, such as easy walking, yoga, bowling, lawn bowling, shuffleboard, or golf mins.)
double
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C70666 (NCI Thesaurus Property)
C2945599 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C16567 (NCI Thesaurus Property)
C0015259 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
QualityofLifeModerateExercisePerformedAssessmentWeekFrequency
Item
Times per week (Moderate exercise - that is, exercise that is not exhausting and which made you perspire lightly, such as fast walking, tennis, easy bicycling, easy swimming, or popular and folk dancing)
double
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C61376 (NCI Thesaurus Property)
C1881878 (UMLS 2011AA Property)
C16567 (NCI Thesaurus Property)
C0015259 (UMLS 2011AA Property)
C29844 (NCI Thesaurus ValueDomain)
C0439230 (UMLS 2011AA ValueDomain)
C25515 (NCI Thesaurus ValueDomain)
C0439603 (UMLS 2011AA ValueDomain)
QualityofLifeModerateExercisePerformedAssessmentDuration
Item
Average duration (Moderate exercise - that is, exercise that is not exhausting and which made you perspire lightly, such as fast walking, tennis, easy bicycling, easy swimming, or popular and folk dancing mins.)
double
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C61376 (NCI Thesaurus Property)
C1881878 (UMLS 2011AA Property)
C16567 (NCI Thesaurus Property)
C0015259 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
QualityofLifeHighExercisePerformedAssessmentWeekFrequency
Item
Times per week (Strenuous exercise - that is, exercise that made your heart beat rapidly and made you sweat, such as running, aerobics classes, cross country skiing, vigorous swimming, or vigorous bicycling)
double
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25227 (NCI Thesaurus Property)
C0205250 (UMLS 2011AA Property)
C16567 (NCI Thesaurus Property)
C0015259 (UMLS 2011AA Property)
C29844 (NCI Thesaurus ValueDomain)
C0439230 (UMLS 2011AA ValueDomain)
C25515 (NCI Thesaurus ValueDomain)
C0439603 (UMLS 2011AA ValueDomain)
QualityofLifeHighExercisePerformedAssessmentDuration
Item
Average duration (Strenuous exercise - that is, exercise that made your heart beat rapidly and made you sweat, such as running, aerobics classes, cross country skiing, vigorous swimming, or vigorous bicycling mins.)
double
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25227 (NCI Thesaurus Property)
C0205250 (UMLS 2011AA Property)
C16567 (NCI Thesaurus Property)
C0015259 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
Item
I have been experiencing generalized muscle weakness over the last week
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C50658 (NCI Thesaurus Property)
C0151786 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.9
Code List
I have been experiencing generalized muscle weakness over the last week
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)
Item
During the past month, how would you rate your sleep quality overall
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C73425 (NCI Thesaurus Property)
C0037313 (UMLS 2011AA Property)
C25283 (NCI Thesaurus Property)
C0332306 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
CL.10
Code List
During the past month, how would you rate your sleep quality overall
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)
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