ID

42788

Description

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

Link

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

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 9/17/21 9/17/21 -
Uploaded on

September 17, 2021

DOI

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License

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

English

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

1 forms  
  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
Description

Header Module

Patient Study ID
Description

Patient Study ID

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Patient Initials (L F M)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Date Completed (dd MMM yyyy)
Description

FormCompletionDate

Data type

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)
Description

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

How is your appetite
Description

PatientAppetiteLossSymptomScale

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25559
UMLS 2011AA Property
C1517945
NCI Thesaurus Property-2
C4876
UMLS 2011AA Property-2
C1457887
NCI Thesaurus Property-3
C25152
UMLS 2011AA Property-3
C0003618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How much fatigue do you have
Description

PatientFatigueAssessmentSymptomScale

Data type

float

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-2
C3036
UMLS 2011AA Property-2
C0015672
How much coughing do you have
Description

PatientChokingCoughWorstDifficultySymptomScale

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C37935
UMLS 2011AA ObjectClass-2
C0010200
NCI Thesaurus ObjectClass-3
C50494
UMLS 2011AA ObjectClass-3
C0008301
NCI Thesaurus Property
C25719
UMLS 2011AA Property
C1522166
NCI Thesaurus Property-2
C62189
UMLS 2011AA Property-2
C1299586
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How much shortness of breath do you have
Description

PatientDyspneaAssessmentSymptomScale

Data type

float

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-2
C2998
UMLS 2011AA Property-2
C0013404
How much blood do you see in your sputum
Description

HemoptysisPresentSymptomScale

Data type

float

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
Description

PatientWorstPainSymptomScale

Data type

float

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-2
C25719
UMLS 2011AA Property-2
C1522166
How bad are your symptoms from lung cancer
Description

LungCarcinomaCurrentSymptomScale

Data type

float

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-2
C4876
UMLS 2011AA Property-2
C1457887
How much has your illness affected your ability to carry out normal activities
Description

PatientGeneralizedActivityInterferenceSymptomScale

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C43431
UMLS 2011AA Property
C0441655
NCI Thesaurus Property-2
C4876
UMLS 2011AA Property-2
C1457887
NCI Thesaurus Property-3
C63764
UMLS 2011AA Property-3
C0205246
NCI Thesaurus Property-4
C72886
UMLS 2011AA Property-4
C0521102
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How would you rate the quality of your life today
Description

PatientQualityofLifeAssessmentScore

Data type

text

Alias
NCI Thesaurus Property
C17047
UMLS 2011AA Property
C0518214
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property-2
C20989
UMLS 2011AA Property-2
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 forms
  1. StudyEvent: ACOSOG-Z4099 Lung Cancer Symptom Scale (LCSS) Form
    1. Reproduced with permission of LCSS Associates. To be completed by the patient.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Patient Study ID
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Patient Initials
Item
Patient Initials (L F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus 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)
PatientAppetiteLossSymptomScale
Item
How is your appetite
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25559 (NCI Thesaurus Property)
C1517945 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property-2)
C1457887 (UMLS 2011AA Property-2)
C25152 (NCI Thesaurus Property-3)
C0003618 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
PatientFatigueAssessmentSymptomScale
Item
How much fatigue do you have
float
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-2)
C0015672 (UMLS 2011AA Property-2)
PatientChokingCoughWorstDifficultySymptomScale
Item
How much coughing do you have
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C37935 (NCI Thesaurus ObjectClass-2)
C0010200 (UMLS 2011AA ObjectClass-2)
C50494 (NCI Thesaurus ObjectClass-3)
C0008301 (UMLS 2011AA ObjectClass-3)
C25719 (NCI Thesaurus Property)
C1522166 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property-2)
C1299586 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
PatientDyspneaAssessmentSymptomScale
Item
How much shortness of breath do you have
float
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-2)
C0013404 (UMLS 2011AA Property-2)
HemoptysisPresentSymptomScale
Item
How much blood do you see in your sputum
float
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C3094 (NCI Thesaurus ObjectClass)
C0019079 (UMLS 2011AA ObjectClass)
PatientWorstPainSymptomScale
Item
How much pain do you have
float
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-2)
C1522166 (UMLS 2011AA Property-2)
LungCarcinomaCurrentSymptomScale
Item
How bad are your symptoms from lung cancer
float
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-2)
C1457887 (UMLS 2011AA Property-2)
PatientGeneralizedActivityInterferenceSymptomScale
Item
How much has your illness affected your ability to carry out normal activities
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C43431 (NCI Thesaurus Property)
C0441655 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property-2)
C1457887 (UMLS 2011AA Property-2)
C63764 (NCI Thesaurus Property-3)
C0205246 (UMLS 2011AA Property-3)
C72886 (NCI Thesaurus Property-4)
C0521102 (UMLS 2011AA Property-4)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
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-2)
C0031809 (UMLS 2011AA Property-2)
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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