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43114

Description

Curative Treatment for Head and Neck Cancer - On-Study Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D4976276-569A-5CEB-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D4976276-569A-5CEB-E034-0003BA12F5E7

Keywords

Versions (6)
  1. 9/20/12 9/20/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 8/11/14 8/11/14 - Martin Dugas
  4. 8/11/14 8/11/14 - Martin Dugas
  5. 1/9/15 1/9/15 - Martin Dugas
  6. 9/20/21 9/20/21 -
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September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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    On-Study - Curative Treatment for Head and Neck Cancer - On-Study Form - 2268312v3.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Curative Treatment for Head and Neck Cancer - On-Study Form
      1. No Instruction available.
    Crf Header
    Description

    Crf Header

    Coordinating Group Protocol No.
    Description

    Protocol ID Coordinating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1711341
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    Coordinating Group Code
    Description

    Coordinating Group Code

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS CUI-1
    C1711341
    NCI Thesaurus ObjectClass
    C17005
    UMLS CUI-2
    C0805701
    NCI Thesaurus ObjectClass-2
    C25462
    NCI Thesaurus Property
    C25364
    Protocol Title
    Description

    Protocol Title

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986303
    NCI Thesaurus ObjectClass
    C25320
    NCI Thesaurus Property
    C42774
    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
    Institution/Affiliate
    Description

    Institution Name

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Other Patient ID
    Description

    Trial subject ID Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Participating Group Code
    Description

    ParticipatingGroupIdentifierCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C25608
    UMLS 2011AA ObjectClass
    C0679823
    NCI Thesaurus ObjectClass-2
    C17005
    UMLS 2011AA ObjectClass-2
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Patient Initials
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Head & Neck: Form Administration
    Description

    Head & Neck: Form Administration

    Person Completing Form
    Description

    Person Completing Form

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    Are data amended? (If data are amended, please circle in red when using paper form)
    Description

    Data amended

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Head & Neck: Patient Assessment
    Description

    Head & Neck: Patient Assessment

    Performance Status (check one)
    Description

    ECOG Performance Status

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS CUI-1
    C1520224
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ValueDomain-2
    C25491
    NCI Thesaurus ObjectClass
    C20641
    Head & Neck: Disease Description
    Description

    Head & Neck: Disease Description

    Date of Initial Pathologic Diagnosis (mm dd yyyy)
    Description

    CancerInitialDiagnosisDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property-2
    C15220
    UMLS 2011AA Property-2
    C0011900
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    Primary Site
    Description

    HeadandNeckTumorPrimaryLocation

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property-2
    C25251
    UMLS 2011AA Property-2
    C0205225
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    Other specify
    Description

    Primary Disease Site

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0449695
    NCI Thesaurus Property
    C25341
    NCI Thesaurus ObjectClass
    C25251
    NCI Thesaurus ObjectClass-2
    C2991
    Is this a second primary in the upper aero-digestive tract (Note: includes patients with second primary when curative treatment is planned.)
    Description

    HeadandNeckTumorSecondOccurrenceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25666
    UMLS 2011AA Property
    C0205436
    NCI Thesaurus Property-2
    C25275
    UMLS 2011AA Property-2
    C2745955
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Name of Referring Institution (If yes, where initial tumor was treated)
    Description

    ReferringInstitutionName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus ObjectClass-2
    C25642
    UMLS 2011AA ObjectClass-2
    C0205543
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain-2
    C21541
    UMLS 2011AA ValueDomain-2
    C0018704
    Histologic Type (values continue on next page)
    Description

    HeadandNeckTumorHistologicCategory

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25526
    UMLS 2011AA Property
    C0205462
    NCI Thesaurus Property-2
    C25161
    UMLS 2011AA Property-2
    C0008902
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ValueDomain-2
    C25526
    UMLS 2011AA ValueDomain-2
    C0205462
    Other specify
    Description

    Histologic Type, other

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C1299220
    NCI Thesaurus ObjectClass
    C3262
    NCI Thesaurus Property
    C25526
    NCI Thesaurus Property-2
    C25161
    Histologic Grade (check highest grade)
    Description

    HeadandNeckTumorHistologicGrade

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25526
    UMLS 2011AA Property
    C0205462
    NCI Thesaurus Property-2
    C25365
    UMLS 2011AA Property-2
    C0678257
    NCI Thesaurus ValueDomain
    C25526
    UMLS 2011AA ValueDomain
    C0205462
    NCI Thesaurus ValueDomain-2
    C18000
    UMLS 2011AA ValueDomain-2
    C0919553
    Clinical T Stage
    Description

    HeadandNeckTumorClinicalTStage

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25398
    UMLS 2011AA Property
    C0205210
    NCI Thesaurus Property-2
    C25728
    UMLS 2011AA Property-2
    C0475455
    NCI Thesaurus ValueDomain
    C16899
    UMLS 2011AA ValueDomain
    C1300072
    Clinical N Stage (overall)
    Description

    HeadandNeckTumorClinicalNStage

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25398
    UMLS 2011AA Property
    C0205210
    NCI Thesaurus Property-2
    C25580
    UMLS 2011AA Property-2
    C0456532
    NCI Thesaurus ValueDomain
    C16899
    UMLS 2011AA ValueDomain
    C1300072
    Clinical N Stage, Right Side
    Description

    HeadandNeckTumorRightNStage

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25228
    UMLS 2011AA Property
    C0205090
    NCI Thesaurus Property-2
    C25580
    UMLS 2011AA Property-2
    C0456532
    NCI Thesaurus ValueDomain
    C16899
    UMLS 2011AA ValueDomain
    C1300072
    Clinical N Stage, Left Side
    Description

    HeadandNeckTumorLeftNStage

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25229
    UMLS 2011AA Property
    C0205091
    NCI Thesaurus Property-2
    C25580
    UMLS 2011AA Property-2
    C0456532
    NCI Thesaurus ValueDomain
    C16899
    UMLS 2011AA ValueDomain
    C1300072
    Clinical M Stage
    Description

    HeadandNeckTumorClinicalMStage

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12418
    UMLS 2011AA ObjectClass-2
    C0460004
    NCI Thesaurus Property
    C25398
    UMLS 2011AA Property
    C0205210
    NCI Thesaurus Property-2
    C25727
    UMLS 2011AA Property-2
    C0456533
    NCI Thesaurus ValueDomain
    C16899
    UMLS 2011AA ValueDomain
    C1300072
    Head & Neck: Prior Health History - Curative
    Description

    Head & Neck: Prior Health History - Curative

    Does the patient have a chronic disease
    Description

    ChronicDiseasePresentInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C25626
    UMLS 2011AA Property
    C0150312
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus ObjectClass-2
    C14141
    UMLS 2011AA ObjectClass-2
    C0205191
    Chronic Disease (If yes,)
    Description

    ChronicDiseaseDiagnosisType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus ObjectClass-2
    C14141
    UMLS 2011AA ObjectClass-2
    C0205191
    Other specify
    Description

    ChronicDiseaseDiagnosisSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus ObjectClass-2
    C14141
    UMLS 2011AA ObjectClass-2
    C0205191
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ValueDomain-2
    C17649
    UMLS 2011AA ValueDomain-2
    C0205394
    Weight Loss in Previous Six Months (check one)
    Description

    Weight Loss past six months

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS CUI-1
    C1262477
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C3828652
    NCI Thesaurus Property
    C3445
    NCI Thesaurus ValueDomain-2
    C25613
    Smoking History
    Description

    SmokingHistoryType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C17934
    UMLS 2011AA ObjectClass
    C0453996
    NCI Thesaurus Property
    C18772
    UMLS 2011AA Property
    C0262926
    Does the patient currently smoke
    Description

    Current Smoker

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C3241966
    NCI Thesaurus Property
    C25471
    NCI Thesaurus ObjectClass
    C17934
    NCI Metathesaurus Property
    C0449865
    Number of Cigarettes per day (If yes,)
    Description

    Smoker amount smoked

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C17934
    UMLS CUI-1
    C1608325
    NCI Thesaurus Property
    C25471
    NCI Metathesaurus Property
    C0449865
    NCI Thesaurus ValueDomain
    C25473
    NCI Thesaurus ValueDomain-2
    C25515
    Time since last cigarette (If no,)
    Description

    Smoking Discontinued Duration

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25484
    UMLS CUI-1
    C0453997
    NCI Thesaurus ObjectClass
    C17934
    NCI Thesaurus ValueDomain
    C25330
    Alcohol Consumption History (1 drink = 1 oz. Whiskey = 12 oz. Beer)
    Description

    AlcoholHistoryType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C18772
    UMLS 2011AA Property
    C0262926
    NCI Thesaurus ObjectClass
    C2190
    UMLS 2011AA ObjectClass
    C0001962
    Does the patient currently consume alcohol
    Description

    AlcoholCurrentUseInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus ObjectClass
    C2190
    UMLS 2011AA ObjectClass
    C0001962
    NCI Thesaurus Property-2
    C25340
    UMLS 2011AA Property-2
    C0457083
    Average Alcohol Consumption (If yes, 1 drink = 1 oz. Whiskey = 12 oz. Beer)
    Description

    AlcoholCurrentUseRangeType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus ObjectClass
    C2190
    UMLS 2011AA ObjectClass
    C0001962
    NCI Thesaurus Property-2
    C25340
    UMLS 2011AA Property-2
    C0457083
    Is the patient an alcoholic
    Description

    AlcoholAssociatedProblemInd

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus Property
    C28020
    UMLS 2011AA Property
    C0033213
    NCI Thesaurus ObjectClass
    C2190
    UMLS 2011AA ObjectClass
    C0001962
    NCI Thesaurus Property-2
    C25281
    UMLS 2011AA Property-2
    C0332281
    Time since last drink (If recovering,)
    Description

    AlcoholDiscontinuedDuration

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25484
    UMLS 2011AA Property
    C1444662
    NCI Thesaurus ObjectClass
    C2190
    UMLS 2011AA ObjectClass
    C0001962
    NCI Thesaurus ValueDomain
    C25330
    UMLS 2011AA ValueDomain
    C0449238
    Does the patient have a past history of swallowing problems (Assessment of Swallowing)
    Description

    SwallowingFunctionPriorDeficitInd-3

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25518
    UMLS 2011AA ObjectClass
    C0542341
    NCI Thesaurus ObjectClass-2
    C38028
    UMLS 2011AA ObjectClass-2
    C0011167
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus Property-2
    C37940
    UMLS 2011AA Property-2
    C0011155
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    How long were swallowing problems apparent (If yes,)
    Description

    SwallowingFunctionPriorDeficitDuration

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25518
    UMLS 2011AA ObjectClass
    C0542341
    NCI Thesaurus ObjectClass-2
    C38028
    UMLS 2011AA ObjectClass-2
    C0011167
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus Property-2
    C37940
    UMLS 2011AA Property-2
    C0011155
    NCI Thesaurus ValueDomain
    C25330
    UMLS 2011AA ValueDomain
    C0449238
    Does the patient currently have swallowing problems
    Description

    SwallowingFunctionCurrentDeficitInd-3

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25518
    UMLS 2011AA ObjectClass
    C0542341
    NCI Thesaurus ObjectClass-2
    C38028
    UMLS 2011AA ObjectClass-2
    C0011167
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus Property-2
    C37940
    UMLS 2011AA Property-2
    C0011155
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    How long have swallowing problems been present (If yes,)
    Description

    SwallowingFunctionCurrentDeficitDuration

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25518
    UMLS 2011AA ObjectClass
    C0542341
    NCI Thesaurus ObjectClass-2
    C38028
    UMLS 2011AA ObjectClass-2
    C0011167
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus Property-2
    C37940
    UMLS 2011AA Property-2
    C0011155
    NCI Thesaurus ValueDomain
    C25330
    UMLS 2011AA ValueDomain
    C0449238
    Does the patient have a past history of tube feedings
    Description

    GavagePriorAdministrationInd-3

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus ObjectClass
    C73430
    UMLS 2011AA ObjectClass
    C0041281
    NCI Thesaurus Property-2
    C25409
    UMLS 2011AA Property-2
    C1533734
    How long were tube feedings given (If yes,)
    Description

    GavagePriorAdministrationDuration

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus ObjectClass
    C73430
    UMLS 2011AA ObjectClass
    C0041281
    NCI Thesaurus Property-2
    C25409
    UMLS 2011AA Property-2
    C1533734
    NCI Thesaurus ValueDomain
    C25330
    UMLS 2011AA ValueDomain
    C0449238
    Does the patient currently require tube feeding
    Description

    GavageCurrentAdministrationInd-3

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus ObjectClass
    C73430
    UMLS 2011AA ObjectClass
    C0041281
    NCI Thesaurus Property-2
    C25409
    UMLS 2011AA Property-2
    C1533734
    Is patient dependent on tube feeding for >50% of nutritional support (If yes,)
    Description

    GavagePrimaryAdministrationInd-3

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C25251
    UMLS 2011AA Property
    C0205225
    NCI Thesaurus ObjectClass
    C73430
    UMLS 2011AA ObjectClass
    C0041281
    NCI Thesaurus Property-2
    C25409
    UMLS 2011AA Property-2
    C1533734
    Normalcy of Diet Rating (Ask the patient what kinds of foods are difficult for him/her to eat. Begin at the low end of the scale. Move up the scale, giving examples of foods in each category and asking patient if s/he can eat those food items. The patient's score is the highest )
    Description

    DietPerformanceStatusAssessmentIntakeScale

    Data type

    text

    Alias
    NCI Metathesaurus ObjectClass
    CL092952
    NCI Thesaurus ObjectClass
    C15222
    UMLS 2011AA ObjectClass
    C0012155
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus ValueDomain-2
    C25538
    UMLS 2011AA ValueDomain-2
    C1512806
    Public Eating Rating (Ask the patient where s/he eats, with whom s/he eats, and whether s/he alters his/her diet according to where s/he is eating. Choose the score that best fits the patient.)
    Description

    DietaryPerformanceStatusAssessmentLocationScale

    Data type

    text

    Alias
    NCI Metathesaurus ObjectClass
    CL092952
    NCI Thesaurus ObjectClass
    C15222
    UMLS 2011AA ObjectClass
    C0012155
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus ValueDomain-2
    C25341
    UMLS 2011AA ValueDomain-2
    C0450429
    Understandability of Speech Rating (Score based on the interviewer's ability to understand the patient during conversation. Choose the score that best fits the patient.)
    Description

    SpeechPerformanceStatusAssessmentComprehensionScale

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ObjectClass
    C38025
    UMLS 2011AA ObjectClass
    C0037817
    NCI Metathesaurus ObjectClass
    CL092952
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    1 forms
    1. StudyEvent: Curative Treatment for Head and Neck Cancer - On-Study Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Crf Header
    Protocol ID Coordinating Group
    Item
    Coordinating Group Protocol No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1711341 (UMLS CUI-2)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Coordinating Group Code
    Item
    Coordinating Group Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C1711341 (UMLS CUI-1)
    C17005 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25462 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Protocol Title
    Item
    Protocol Title
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986303 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C42774 (NCI Thesaurus Property)
    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)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Trial subject ID Participating Group
    Item
    Other Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    ParticipatingGroupIdentifierCode
    Item
    Participating Group Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C25608 (NCI Thesaurus ObjectClass)
    C0679823 (UMLS 2011AA ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C1257890 (UMLS 2011AA ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Item Group
    Head & Neck: Form Administration
    Person Completing Form
    Item
    Person Completing Form
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Data amended
    Item
    Are data amended? (If data are amended, please circle in red when using paper form)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item Group
    Head & Neck: Patient Assessment
    Item
    Performance Status (check one)
    text
    C25664 (NCI Thesaurus ValueDomain)
    C1520224 (UMLS CUI-1)
    C25367 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus ValueDomain-2)
    C20641 (NCI Thesaurus ObjectClass)
    CL.2
    Code List
    Performance Status (check one)
    CL Item
    Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
    CL Item
    Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
    CL Item
    Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
    CL Item
    Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
    CL Item
    Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
    Item Group
    Head & Neck: Disease Description
    CancerInitialDiagnosisDate
    Item
    Date of Initial Pathologic Diagnosis (mm dd yyyy)
    date
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property-2)
    C0011900 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Item
    Primary Site
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25251 (NCI Thesaurus Property-2)
    C0205225 (UMLS 2011AA Property-2)
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    CL.3
    Code List
    Primary Site
    CL Item
    Lip And Oral Cavity (Lip and oral cavity)
    CL Item
    Oral Cavity Nos (Oral cavity NOS)
    CL Item
    Oral Tongue (Oral Tongue)
    CL Item
    Floor Of Mouth (Floor of mouth)
    C0026638 (NCI Metathesaurus)
    CL Item
    Buccal Mucosa (Buccal mucosa)
    C12505 (NCI Thesaurus)
    C1578559 (UMLS 2011AA)
    CL Item
    Lower Gingiva (Lower gingiva)
    CL Item
    Upper Gingiva (Upper gingiva)
    CL Item
    Retromolar Trigone (Retromolar trigone)
    CL Item
    Hard Palate (Hard palate)
    C12230 (NCI Thesaurus)
    C0226901 (UMLS 2011AA)
    CL Item
    Nasopharynx Nos (Nasopharynx NOS)
    CL Item
    Posterior Superior Wall (Posterior superior wall)
    CL Item
    Lateral Wall (Lateral wall)
    CL Item
    Oropharynx Nos (Oropharynx NOS)
    CL Item
    Supraglottic Larynx (Supraglottic larynx)
    CL Item
    Faucial Arch (Faucial arch)
    CL Item
    Tonsillar Fossa Tonsil (Tonsillar fossa, tonsil)
    CL Item
    Base Of Tongue (Base of tongue)
    C0226958 (NCI Metathesaurus)
    CL Item
    Posterior Pharyngeal Wall (Posterior pharyngeal wall)
    CL Item
    Soft Palate (Soft palate)
    C12231 (NCI Thesaurus)
    C0030219 (UMLS 2011AA)
    CL Item
    Hypopharynx Nos (Hypopharynx NOS)
    CL Item
    Pyriform Fossa (Pyriform fossa)
    CL Item
    Postcricoid Area (Postcricoid area)
    CL Item
    Posterior Wall (Posterior wall)
    CL Item
    Salivary Glands Nos (Salivary glands NOS)
    CL Item
    Parotid (Parotid)
    CL Item
    Submandibular (Submandibular)
    CL Item
    Sublingual (Sublingual)
    C89785 (NCI Thesaurus)
    CL Item
    Minor Salivary Glands (Minor salivary glands)
    CL Item
    Larynx Nos (Larynx NOS)
    CL Item
    Glottic Larynx (Glottic larynx)
    CL Item
    Subglottic Larynx (Subglottic larynx)
    CL Item
    Paranasal Sinuses Nos (Paranasal sinuses NOS)
    CL Item
    Antrum (Antrum)
    CL Item
    Ethmoid (Ethmoid)
    CL Item
    Sphenoid (Sphenoid)
    CL Item
    Frontal (Frontal)
    CL Item
    Nose Nos (Nose NOS)
    CL Item
    Nasal Cavity (Nasal cavity)
    C12424 (NCI Thesaurus)
    C0027423 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    Primary Disease Site
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0449695 (UMLS CUI-1)
    C25341 (NCI Thesaurus Property)
    C25251 (NCI Thesaurus ObjectClass)
    C2991 (NCI Thesaurus ObjectClass-2)
    HeadandNeckTumorSecondOccurrenceInd-2
    Item
    Is this a second primary in the upper aero-digestive tract (Note: includes patients with second primary when curative treatment is planned.)
    boolean
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25666 (NCI Thesaurus Property)
    C0205436 (UMLS 2011AA Property)
    C25275 (NCI Thesaurus Property-2)
    C2745955 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    ReferringInstitutionName
    Item
    Name of Referring Institution (If yes, where initial tumor was treated)
    text
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25642 (NCI Thesaurus ObjectClass-2)
    C0205543 (UMLS 2011AA ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    C0018704 (UMLS 2011AA ValueDomain-2)
    Item
    Histologic Type (values continue on next page)
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25526 (NCI Thesaurus Property)
    C0205462 (UMLS 2011AA Property)
    C25161 (NCI Thesaurus Property-2)
    C0008902 (UMLS 2011AA Property-2)
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C25526 (NCI Thesaurus ValueDomain-2)
    C0205462 (UMLS 2011AA ValueDomain-2)
    CL.5
    Code List
    Histologic Type (values continue on next page)
    CL Item
    Carcinoma In Situ (specify Histologic Type) (Carcinoma in situ)
    CL Item
    Squamous Cell Carcinoma Keratinizing (Squamous cell carcinoma, keratinizing)
    CL Item
    Squamous Cell Carcinoma Non-keratinizing (Squamous cell carcinoma, non-keratinizing)
    CL Item
    Verrucous Squamous Cell Carcinoma (Verrucous squamous cell carcinoma)
    CL Item
    Adenoid Squamous Cell Carcinoma (Adenoid squamous cell carcinoma)
    CL Item
    Basaloid Squamous Cell Carcinoma (Basaloid squamous cell carcinoma)
    CL Item
    Adenosquamous Carcinoma (Adenosquamous carcinoma)
    C3727 (NCI Thesaurus)
    C0206623 (UMLS 2011AA)
    CL Item
    Adenocarcinoma (Adenocarcinoma)
    C2852 (NCI Thesaurus)
    C0001418 (UMLS 2011AA)
    CL Item
    Spindle Cell Carcinoma (Spindle cell carcinoma)
    CL Item
    Acinic Cell Carcinoma (Acinic cell carcinoma)
    CL Item
    Mucoepidermoid Carcinoma (Mucoepidermoid carcinoma)
    C3772 (NCI Thesaurus)
    C0206694 (UMLS 2011AA)
    CL Item
    Adenoid Cystic Carcinoma (Adenoid cystic carcinoma)
    C2970 (NCI Thesaurus)
    C0010606 (UMLS 2011AA)
    CL Item
    Carcinoma In Pleomorphic Adenoma (Carcinoma in pleomorphic adenoma)
    CL Item
    Epithelial-myoepithelial Carcinoma (Epithelial-myoepithelial carcinoma)
    C4199 (NCI Thesaurus)
    C0334392 (UMLS 2011AA)
    CL Item
    Clear Cell Carcinoma (Clear cell carcinoma)
    CL Item
    Giant Cell Carcinoma (Giant cell carcinoma)
    C3779 (NCI Thesaurus)
    C0206703 (UMLS 2011AA)
    CL Item
    Small Cell Carcinoma (Small cell carcinoma)
    C3915 (NCI Thesaurus)
    C0262584 (UMLS 2011AA)
    CL Item
    Salivary Duct Carcinoma (Salivary duct carcinoma)
    C5904 (NCI Thesaurus)
    C1301194 (UMLS 2011AA)
    CL Item
    Carcinoid Tumor (Carcinoid tumor)
    C2915 (NCI Thesaurus)
    C0007095 (UMLS 2011AA)
    CL Item
    Atypical Carcinoid Tumor (Atypical carcinoid tumor)
    CL017927 (NCI Metathesaurus)
    CL Item
    Lymphoepithelial Carcinoma (Lymphoepithelial carcinoma)
    CL Item
    Undifferentiated Carcinoma (Undifferentiated carcinoma)
    C3692 (NCI Thesaurus)
    C0205698 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    Histologic Type, other
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1299220 (UMLS CUI-1)
    C3262 (NCI Thesaurus ObjectClass)
    C25526 (NCI Thesaurus Property)
    C25161 (NCI Thesaurus Property-2)
    Item
    Histologic Grade (check highest grade)
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25526 (NCI Thesaurus Property)
    C0205462 (UMLS 2011AA Property)
    C25365 (NCI Thesaurus Property-2)
    C0678257 (UMLS 2011AA Property-2)
    C25526 (NCI Thesaurus ValueDomain)
    C0205462 (UMLS 2011AA ValueDomain)
    C18000 (NCI Thesaurus ValueDomain-2)
    C0919553 (UMLS 2011AA ValueDomain-2)
    CL.6
    Code List
    Histologic Grade (check highest grade)
    CL Item
    Well Differentiated (grade I) (Well differentiated (Grade I))
    CL Item
    Moderately Differentiated (grade Ii) (Moderately differentiated (Grade II))
    CL Item
    Poorly Differentiated (grade Iii) (Poorly differentiated (Grade III))
    CL Item
    Undifferentiated (grade Iv) (Undifferentiated (Grade IV))
    CL Item
    Cannot Be Assessed (grade X) (Cannot be assessed (Grade X))
    Item
    Clinical T Stage
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25398 (NCI Thesaurus Property)
    C0205210 (UMLS 2011AA Property)
    C25728 (NCI Thesaurus Property-2)
    C0475455 (UMLS 2011AA Property-2)
    C16899 (NCI Thesaurus ValueDomain)
    C1300072 (UMLS 2011AA ValueDomain)
    CL.7
    Code List
    Clinical T Stage
    CL Item
    T0, According To Ajcc Criteria (T0)
    CL Item
    Tis, According To Ajcc Criteria (Tis)
    CL Item
    T1, According To Ajcc Criteria (T1)
    CL Item
    T2, According To Ajcc Criteria (T2)
    CL Item
    T3, According To Ajcc Criteria (T3)
    CL Item
    T4a, According To Ajcc Guidelines (T4a)
    CL Item
    T4b, According To Ajcc Guidelines (T4b)
    CL Item
    Tx, According To Ajcc Criteria (TX)
    Item
    Clinical N Stage (overall)
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25398 (NCI Thesaurus Property)
    C0205210 (UMLS 2011AA Property)
    C25580 (NCI Thesaurus Property-2)
    C0456532 (UMLS 2011AA Property-2)
    C16899 (NCI Thesaurus ValueDomain)
    C1300072 (UMLS 2011AA ValueDomain)
    CL.8
    Code List
    Clinical N Stage (overall)
    CL Item
    N0, According To Ajcc Guidelines (N0)
    CL Item
    N1, According To Ajcc Criteria (N1)
    CL Item
    N2, According To Ajcc Criteria (N2)
    CL Item
    N2a, According To Ajcc Guidelines (N2a)
    CL Item
    N2b, According To Ajcc Guidelines (N2b)
    CL Item
    N2c, According To Ajcc Guidelines (N2c)
    CL Item
    N3, According To Ajcc Guidelines (N3)
    Item
    Clinical N Stage, Right Side
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25228 (NCI Thesaurus Property)
    C0205090 (UMLS 2011AA Property)
    C25580 (NCI Thesaurus Property-2)
    C0456532 (UMLS 2011AA Property-2)
    C16899 (NCI Thesaurus ValueDomain)
    C1300072 (UMLS 2011AA ValueDomain)
    CL.9
    Code List
    Clinical N Stage, Right Side
    CL Item
    N0, According To Ajcc Guidelines (N0)
    CL Item
    N1, According To Ajcc Criteria (N1)
    CL Item
    N2, According To Ajcc Criteria (N2)
    CL Item
    N2a, According To Ajcc Guidelines (N2a)
    CL Item
    N2b, According To Ajcc Guidelines (N2b)
    CL Item
    N2c, According To Ajcc Guidelines (N2c)
    CL Item
    N3, According To Ajcc Guidelines (N3)
    Item
    Clinical N Stage, Left Side
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25229 (NCI Thesaurus Property)
    C0205091 (UMLS 2011AA Property)
    C25580 (NCI Thesaurus Property-2)
    C0456532 (UMLS 2011AA Property-2)
    C16899 (NCI Thesaurus ValueDomain)
    C1300072 (UMLS 2011AA ValueDomain)
    CL.10
    Code List
    Clinical N Stage, Left Side
    CL Item
    N0, According To Ajcc Guidelines (N0)
    CL Item
    N1, According To Ajcc Criteria (N1)
    CL Item
    N2, According To Ajcc Criteria (N2)
    CL Item
    N2a, According To Ajcc Guidelines (N2a)
    CL Item
    N2b, According To Ajcc Guidelines (N2b)
    CL Item
    N2c, According To Ajcc Guidelines (N2c)
    CL Item
    N3, According To Ajcc Guidelines (N3)
    Item
    Clinical M Stage
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12418 (NCI Thesaurus ObjectClass-2)
    C0460004 (UMLS 2011AA ObjectClass-2)
    C25398 (NCI Thesaurus Property)
    C0205210 (UMLS 2011AA Property)
    C25727 (NCI Thesaurus Property-2)
    C0456533 (UMLS 2011AA Property-2)
    C16899 (NCI Thesaurus ValueDomain)
    C1300072 (UMLS 2011AA ValueDomain)
    CL.11
    Code List
    Clinical M Stage
    CL Item
    M0, According To Ajcc Guidelines (M0)
    CL Item
    M1, According To Ajcc Staging Definitions (M1)
    CL Item
    Mx, According To Ajcc Guidelines (MX)
    Item Group
    Head & Neck: Prior Health History - Curative
    ChronicDiseasePresentInd-3
    Item
    Does the patient have a chronic disease
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25626 (NCI Thesaurus Property)
    C0150312 (UMLS 2011AA Property)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C14141 (NCI Thesaurus ObjectClass-2)
    C0205191 (UMLS 2011AA ObjectClass-2)
    Item
    Chronic Disease (If yes,)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C14141 (NCI Thesaurus ObjectClass-2)
    C0205191 (UMLS 2011AA ObjectClass-2)
    CL.13
    Code List
    Chronic Disease (If yes,)
    CL Item
    Coronary Artery Disease (Coronary Artery disease)
    CL Item
    Diabetes (Diabetes)
    CL Item
    Gastrointestinal Disease (Gastrointestinal Disease)
    CL Item
    High Blood Pressure (High Blood Pressure)
    CL Item
    Neurologic Disease (Neurologic disease)
    CL Item
    Peripheral Vascular Disease (Peripheral Vascular disease)
    CL Item
    Respiratory Problems (Respiratory problems)
    CL Item
    Other, Specify (Other)
    ChronicDiseaseDiagnosisSpecify
    Item
    Other specify
    text
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C14141 (NCI Thesaurus ObjectClass-2)
    C0205191 (UMLS 2011AA ObjectClass-2)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus ValueDomain-2)
    C0205394 (UMLS 2011AA ValueDomain-2)
    Item
    Weight Loss in Previous Six Months (check one)
    text
    C25664 (NCI Thesaurus ValueDomain)
    C1262477 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C3828652 (UMLS CUI-2)
    C3445 (NCI Thesaurus Property)
    C25613 (NCI Thesaurus ValueDomain-2)
    CL.14
    Code List
    Weight Loss in Previous Six Months (check one)
    CL Item
    <5% Of Body Weight (<5% of body weight)
    CL Item
    5 To <10% Of Body Weight (5 to < 10% of body weight)
    CL Item
    10 To <20% Of Body Weight (10 to <20% of body weight)
    CL Item
    > Or = 20% Of Body Weight (> or = 20% of body weight)
    Item
    Smoking History
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C17934 (NCI Thesaurus ObjectClass)
    C0453996 (UMLS 2011AA ObjectClass)
    C18772 (NCI Thesaurus Property)
    C0262926 (UMLS 2011AA Property)
    CL.15
    Code List
    Smoking History
    CL Item
    Never Smoked (Never smoked)
    CL Item
    Pipe Or Cigar Smoker Only (Pipe or cigar smoker only)
    CL Item
    Cigarette Smoker <20 Pack-years (Cigarette smoker, <20 pack-years)
    CL Item
    Cigarette Smoker 20-40 Pack-years (Cigarette smoker, 20-40 pack-years)
    CL Item
    Cigarette Smoker >40 Pack-years (Cigarette smoker, >40 pack-years)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Current Smoker
    Item
    Does the patient currently smoke
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C3241966 (UMLS CUI-1)
    C25471 (NCI Thesaurus Property)
    C17934 (NCI Thesaurus ObjectClass)
    C0449865 (NCI Metathesaurus Property)
    Item
    Number of Cigarettes per day (If yes,)
    text
    C17934 (NCI Thesaurus ObjectClass)
    C1608325 (UMLS CUI-1)
    C25471 (NCI Thesaurus Property)
    C0449865 (NCI Metathesaurus Property)
    C25473 (NCI Thesaurus ValueDomain)
    C25515 (NCI Thesaurus ValueDomain-2)
    CL.17
    Code List
    Number of Cigarettes per day (If yes,)
    CL Item
    Fewer Than 10 Cigarettes (Fewer than 10 cigarettes)
    CL Item
    10 To 20 Cigarettes (10 to 20 cigarettes)
    CL Item
    More Than 20 Cigarettes (more than 20 cigarettes)
    Item
    Time since last cigarette (If no,)
    text
    C25484 (NCI Thesaurus Property)
    C0453997 (UMLS CUI-1)
    C17934 (NCI Thesaurus ObjectClass)
    C25330 (NCI Thesaurus ValueDomain)
    CL.18
    Code List
    Time since last cigarette (If no,)
    CL Item
    Less Than 1 Month (Less than 1 month)
    CL Item
    1 Month To <6 Months (1 month to <6 months)
    CL Item
    6 Months To <1 Year (6 months to <1 year)
    CL Item
    1 Year To <5 Years (1 year to <5 years)
    CL Item
    5 Years To <10 Years (5 years to <10 years)
    CL Item
    More Than 10 Years (More than 10 years)
    CL Item
    Never Smoked (Never smoked)
    Item
    Alcohol Consumption History (1 drink = 1 oz. Whiskey = 12 oz. Beer)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C18772 (NCI Thesaurus Property)
    C0262926 (UMLS 2011AA Property)
    C2190 (NCI Thesaurus ObjectClass)
    C0001962 (UMLS 2011AA ObjectClass)
    CL.19
    Code List
    Alcohol Consumption History (1 drink = 1 oz. Whiskey = 12 oz. Beer)
    CL Item
    Fewer Than 12 Drinks In Lifetime (Fewer than 12 drinks in lifetime)
    CL Item
    Fewer Than 12 Drinks In Average Year (Fewer than 12 drinks in average year)
    CL Item
    1 To 12 Drinks Per Month In Average Year (1 to 12 drinks per month in average year)
    CL Item
    More Than 4 Drinks Per Week In Average Year (More than 4 drinks per week in average year)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    AlcoholCurrentUseInd-2
    Item
    Does the patient currently consume alcohol
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C2190 (NCI Thesaurus ObjectClass)
    C0001962 (UMLS 2011AA ObjectClass)
    C25340 (NCI Thesaurus Property-2)
    C0457083 (UMLS 2011AA Property-2)
    Item
    Average Alcohol Consumption (If yes, 1 drink = 1 oz. Whiskey = 12 oz. Beer)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C2190 (NCI Thesaurus ObjectClass)
    C0001962 (UMLS 2011AA ObjectClass)
    C25340 (NCI Thesaurus Property-2)
    C0457083 (UMLS 2011AA Property-2)
    CL.21
    Code List
    Average Alcohol Consumption (If yes, 1 drink = 1 oz. Whiskey = 12 oz. Beer)
    CL Item
    Less Than 1 Drink Per Month (Less than 1 drink per month)
    CL Item
    1 To 5 Drinks Per Month (1 to 5 drinks per month)
    CL Item
    1 To 10 Drinks Per Week (1 to 10 drinks per week)
    CL Item
    10 To 30 Drinks Per Week (10 to 30 drinks per week)
    CL Item
    More Than 30 Drinks Per Week (More than 30 drinks per week)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Is the patient an alcoholic
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C28020 (NCI Thesaurus Property)
    C0033213 (UMLS 2011AA Property)
    C2190 (NCI Thesaurus ObjectClass)
    C0001962 (UMLS 2011AA ObjectClass)
    C25281 (NCI Thesaurus Property-2)
    C0332281 (UMLS 2011AA Property-2)
    CL.22
    Code List
    Is the patient an alcoholic
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes Currently (Yes, currently)
    CL Item
    Yes Recovering (Yes, recovering)
    Item
    Time since last drink (If recovering,)
    text
    C25484 (NCI Thesaurus Property)
    C1444662 (UMLS 2011AA Property)
    C2190 (NCI Thesaurus ObjectClass)
    C0001962 (UMLS 2011AA ObjectClass)
    C25330 (NCI Thesaurus ValueDomain)
    C0449238 (UMLS 2011AA ValueDomain)
    CL.23
    Code List
    Time since last drink (If recovering,)
    CL Item
    Less Than 1 Month (Less than 1 month)
    CL Item
    1 Month To <6 Months (1 month to <6 months)
    CL Item
    6 Months To <1 Year (6 months to <1 year)
    CL Item
    1 Year To <5 Years (1 year to <5 years)
    CL Item
    5 Years To <10 Years (5 years to <10 years)
    CL Item
    More Than 10 Years (More than 10 years)
    Item
    Does the patient have a past history of swallowing problems (Assessment of Swallowing)
    text
    C25518 (NCI Thesaurus ObjectClass)
    C0542341 (UMLS 2011AA ObjectClass)
    C38028 (NCI Thesaurus ObjectClass-2)
    C0011167 (UMLS 2011AA ObjectClass-2)
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C37940 (NCI Thesaurus Property-2)
    C0011155 (UMLS 2011AA Property-2)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    CL.24
    Code List
    Does the patient have a past history of swallowing problems (Assessment of Swallowing)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    How long were swallowing problems apparent (If yes,)
    text
    C25518 (NCI Thesaurus ObjectClass)
    C0542341 (UMLS 2011AA ObjectClass)
    C38028 (NCI Thesaurus ObjectClass-2)
    C0011167 (UMLS 2011AA ObjectClass-2)
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C37940 (NCI Thesaurus Property-2)
    C0011155 (UMLS 2011AA Property-2)
    C25330 (NCI Thesaurus ValueDomain)
    C0449238 (UMLS 2011AA ValueDomain)
    CL.25
    Code List
    How long were swallowing problems apparent (If yes,)
    CL Item
    Less Than 1 Month (Less than 1 month)
    CL Item
    1 To <7 Months (1 to <7 months)
    CL Item
    7 To <13 Months (7 to <13 months)
    CL Item
    13 To <19 Months (13 to <19 months)
    CL Item
    19 To <24 Months (19 to <24 months)
    CL Item
    2 Years Or Longer (2 years or longer)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Does the patient currently have swallowing problems
    text
    C25518 (NCI Thesaurus ObjectClass)
    C0542341 (UMLS 2011AA ObjectClass)
    C38028 (NCI Thesaurus ObjectClass-2)
    C0011167 (UMLS 2011AA ObjectClass-2)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C37940 (NCI Thesaurus Property-2)
    C0011155 (UMLS 2011AA Property-2)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    CL.26
    Code List
    Does the patient currently have swallowing problems
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    How long have swallowing problems been present (If yes,)
    text
    C25518 (NCI Thesaurus ObjectClass)
    C0542341 (UMLS 2011AA ObjectClass)
    C38028 (NCI Thesaurus ObjectClass-2)
    C0011167 (UMLS 2011AA ObjectClass-2)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C37940 (NCI Thesaurus Property-2)
    C0011155 (UMLS 2011AA Property-2)
    C25330 (NCI Thesaurus ValueDomain)
    C0449238 (UMLS 2011AA ValueDomain)
    CL.27
    Code List
    How long have swallowing problems been present (If yes,)
    CL Item
    Less Than 1 Month (Less than 1 month)
    CL Item
    1 To <7 Months (1 to <7 months)
    CL Item
    7 To <13 Months (7 to <13 months)
    CL Item
    13 To <19 Months (13 to <19 months)
    CL Item
    19 To <24 Months (19 to <24 months)
    CL Item
    2 Years Or Longer (2 years or longer)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Does the patient have a past history of tube feedings
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C73430 (NCI Thesaurus ObjectClass)
    C0041281 (UMLS 2011AA ObjectClass)
    C25409 (NCI Thesaurus Property-2)
    C1533734 (UMLS 2011AA Property-2)
    CL.28
    Code List
    Does the patient have a past history of tube feedings
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    How long were tube feedings given (If yes,)
    text
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C73430 (NCI Thesaurus ObjectClass)
    C0041281 (UMLS 2011AA ObjectClass)
    C25409 (NCI Thesaurus Property-2)
    C1533734 (UMLS 2011AA Property-2)
    C25330 (NCI Thesaurus ValueDomain)
    C0449238 (UMLS 2011AA ValueDomain)
    CL.29
    Code List
    How long were tube feedings given (If yes,)
    CL Item
    Less Than 1 Month (Less than 1 month)
    CL Item
    1 To <7 Months (1 to <7 months)
    CL Item
    7 To <13 Months (7 to <13 months)
    CL Item
    13 To <19 Months (13 to <19 months)
    CL Item
    19 To <24 Months (19 to <24 months)
    CL Item
    2 Years Or Longer (2 years or longer)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Does the patient currently require tube feeding
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C73430 (NCI Thesaurus ObjectClass)
    C0041281 (UMLS 2011AA ObjectClass)
    C25409 (NCI Thesaurus Property-2)
    C1533734 (UMLS 2011AA Property-2)
    CL.30
    Code List
    Does the patient currently require tube feeding
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Is patient dependent on tube feeding for >50% of nutritional support (If yes,)
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25251 (NCI Thesaurus Property)
    C0205225 (UMLS 2011AA Property)
    C73430 (NCI Thesaurus ObjectClass)
    C0041281 (UMLS 2011AA ObjectClass)
    C25409 (NCI Thesaurus Property-2)
    C1533734 (UMLS 2011AA Property-2)
    CL.31
    Code List
    Is patient dependent on tube feeding for >50% of nutritional support (If yes,)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Normalcy of Diet Rating (Ask the patient what kinds of foods are difficult for him/her to eat. Begin at the low end of the scale. Move up the scale, giving examples of foods in each category and asking patient if s/he can eat those food items. The patient's score is the highest )
    text
    CL092952 (NCI Metathesaurus ObjectClass)
    C15222 (NCI Thesaurus ObjectClass)
    C0012155 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C25538 (NCI Thesaurus ValueDomain-2)
    C1512806 (UMLS 2011AA ValueDomain-2)
    CL.32
    Code List
    Normalcy of Diet Rating (Ask the patient what kinds of foods are difficult for him/her to eat. Begin at the low end of the scale. Move up the scale, giving examples of foods in each category and asking patient if s/he can eat those food items. The patient's score is the highest )
    CL Item
    100= Full Diet (no Restrictions) (100)
    CL Item
    90= Full Diet (liquid Assist) (90)
    CL Item
    80= All Meat (80)
    CL Item
    70= Raw Carrots, Celery (70)
    CL Item
    60= Dry Bread And Crackers (60)
    CL Item
    50= Soft, Chewable Foods (e.g., Macaroni, Canned/soft Fruits, Cooked Vegetables, Fish, Hamburger, Small Pieces Of Meat) (50)
    CL Item
    40= Soft Foods Requiring No Chewing (e.g., Mashed Potatoes, Apple Sauce, Pudding) (40)
    CL Item
    30= Pureed Foods (in Blender) (30)
    CL Item
    20= Warm Liquids (20)
    CL Item
    10= Cold Liquids (10)
    CL Item
    0= Non-oral Feeding (tube Fed) (0)
    Item
    Public Eating Rating (Ask the patient where s/he eats, with whom s/he eats, and whether s/he alters his/her diet according to where s/he is eating. Choose the score that best fits the patient.)
    text
    CL092952 (NCI Metathesaurus ObjectClass)
    C15222 (NCI Thesaurus ObjectClass)
    C0012155 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C25341 (NCI Thesaurus ValueDomain-2)
    C0450429 (UMLS 2011AA ValueDomain-2)
    CL.33
    Code List
    Public Eating Rating (Ask the patient where s/he eats, with whom s/he eats, and whether s/he alters his/her diet according to where s/he is eating. Choose the score that best fits the patient.)
    CL Item
    100= No Restriction Of Place, Food Or Companion (eats Out At Any Opportunity) (100)
    CL Item
    75= No Restriction Of Place, But Restricts Diet When In Public (eats Anywhere, But May Limit Intake To Less "messy" Foods, E.g., Liquids) (75)
    CL Item
    50= Eats Only In Presence Of Selected Persons In Selected Places (50)
    CL Item
    25= Eats Only At Home In Presence Of Selected Persons (25)
    CL Item
    0= Always Eats Alone (0)
    Item
    Understandability of Speech Rating (Score based on the interviewer's ability to understand the patient during conversation. Choose the score that best fits the patient.)
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C38025 (NCI Thesaurus ObjectClass)
    C0037817 (UMLS 2011AA ObjectClass)
    CL092952 (NCI Metathesaurus ObjectClass)
    CL.34
    Code List
    Understandability of Speech Rating (Score based on the interviewer's ability to understand the patient during conversation. Choose the score that best fits the patient.)
    CL Item
    100= Always Understandable (100)
    CL Item
    75= Understandable Most Of The Time; Occasional Repetition Necessary (75)
    CL Item
    50= Usually Understandable; Face-to-face Contact Necessary (50)
    CL Item
    25= Difficult To Understand (25)
    CL Item
    0= Never Understandable; May Use Written Communication (0)
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