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ID

43174

Description

Baseline Medical History form for C3D 3.12 Adopters Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF0830C9-70C7-12CC-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF0830C9-70C7-12CC-E034-0003BA3F9857

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Versions (2)
  1. 9/20/12 9/20/12 -
  2. 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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    Pre-Study - BASELINE MEDICAL HISTORY - 2393057v1.0

    English

    Dates will appear as 'DD-MON-YYYY'

    1 forms  
    1. StudyEvent: BASELINE MEDICAL HISTORY
      1. Dates will appear as 'DD-MON-YYYY'
    Baseline Medical History
    Description

    Baseline Medical History

    Evaluation Date
    Description

    EvaluationDate

    Data type

    date

    Alias
    NCI Thesaurus Property
    C25164 (undefined)
    UMLS 2011AA Property
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C25214 (undefined)
    UMLS 2011AA ObjectClass
    C0220825 (Evaluation)
    LOINC
    LP36377-7
    Body System Type
    Description

    BodySystemType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    NCI Thesaurus ObjectClass
    C13041 (undefined)
    UMLS 2011AA ObjectClass
    C1268086 (Body structure)
    SNOMED
    123037004
    LOINC
    LP28569-9
    NCI Thesaurus Property
    C25700 (undefined)
    UMLS 2011AA Property
    C0449913 (System)
    SNOMED
    246333005
    Medical History Description
    Description

    MedicalHistoryDescription

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus Property
    C25401 (undefined)
    UMLS 2011AA Property
    C0205161 (Abnormal)
    SNOMED
    263654008
    LOINC
    LP28764-6
    NCI Thesaurus Property
    C18772 (undefined)
    UMLS 2011AA Property
    C0262926 (Medical History)
    SNOMED
    392521001
    LOINC
    LP6817-3
    NCI Thesaurus ObjectClass
    C25261 (undefined)
    UMLS 2011AA ObjectClass
    C0205476 (Medical)
    SNOMED
    74188005
    Comments
    Description

    Comments

    Note Date
    Description

    NoteDate

    Data type

    date

    Alias
    NCI Thesaurus Property
    C25164 (undefined)
    UMLS 2011AA Property
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Metathesaurus ObjectClass
    C1317574 (Note (document))
    LOINC
    LP72988-6
    Research Comments Text
    Description

    ResearchCommentsText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ObjectClass
    C15319 (undefined)
    NCI Thesaurus Property
    C25393 (undefined)
    UMLS 2011AA Property
    C0282411 (Published Comment)
    LOINC
    MTHU018874
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    Similar models

    Dates will appear as 'DD-MON-YYYY'

    1 forms
    1. StudyEvent: BASELINE MEDICAL HISTORY
      1. Dates will appear as 'DD-MON-YYYY'
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Baseline Medical History
    EvaluationDate
    Item
    Evaluation Date
    date
    C25164 (NCI Thesaurus Property)
    C0011008 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus ObjectClass)
    C0220825 (UMLS 2011AA ObjectClass)
    Item
    Body System Type
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C13041 (NCI Thesaurus ObjectClass)
    C1268086 (UMLS 2011AA ObjectClass)
    C25700 (NCI Thesaurus Property)
    C0449913 (UMLS 2011AA Property)
    CL.1
    Code List
    Body System Type
    CL Item
    Abdomen (ABDOMEN)
    C12664 (NCI Thesaurus)
    C0230168 (UMLS 2011AA)
    CL Item
    Allergy Or Drug Sensitivity History (Allergy/Drug Sensitivity)
    CL Item
    Appearance (Appearance)
    CL Item
    Body As A Whole (Body as a Whole)
    CL Item
    Breasts (BREASTS)
    C12971 (NCI Thesaurus)
    C0006141 (UMLS 2011AA)
    CL Item
    Cardiovascular (CARDIOVASCULAR)
    C25292 (NCI Thesaurus)
    C0007226 (UMLS 2011AA)
    CL Item
    Central Nervous System (Central Nervous System)
    C12438 (NCI Thesaurus)
    C3714787 (UMLS 2011AA)
    CL Item
    Chest (Chest)
    C25389 (NCI Thesaurus)
    C0817096 (UMLS 2011AA)
    CL Item
    Constitutional (Constitutional)
    C37931 (NCI Thesaurus)
    C1511487 (UMLS 2011AA)
    CL Item
    Dermatologic (DERMATOLOGIC)
    C0205489 (NCI Metathesaurus)
    CL Item
    Endocrine/metabolic (ENDOCRINE/METABOLIC)
    CL Item
    Extremities (Extremities)
    C30140 (NCI Thesaurus)
    CL Item
    Gastrointestinal (GASTROINTESTINAL)
    C13359 (NCI Thesaurus)
    C0521362 (UMLS 2011AA)
    CL Item
    Genitalia (GENITALIA)
    C25177 (NCI Thesaurus)
    C0017420 (UMLS 2011AA)
    CL Item
    Genitourinary (Genitourinary)
    CL Item
    H/e/e/n/t (H/E/E/N/T)
    CL Item
    Hematologic (HEMATOLOGIC)
    C0205488 (NCI Metathesaurus)
    CL Item
    Hematopoietic/lymph (HEMATOPOIETIC/LYMPH)
    C12745 (NCI Thesaurus)
    C0024204 (UMLS 2011AA)
    CL Item
    Hepatic (Hepatic)
    C13308 (NCI Thesaurus)
    C0205054 (UMLS 2011AA)
    CL Item
    Immune (IMMUNE)
    C17997 (NCI Thesaurus)
    C0439662 (UMLS 2011AA)
    CL Item
    Integumentary/hair (Integumentary/Hair)
    CL Item
    Musculoskeletal (MUSCULOSKELETAL)
    C25348 (NCI Thesaurus)
    C0497254 (UMLS 2011AA)
    CL Item
    Neck (NECK)
    C13063 (NCI Thesaurus)
    C0027530 (UMLS 2011AA)
    CL Item
    Neurologic (NEUROLOGIC)
    C25262 (NCI Thesaurus)
    C0205494 (UMLS 2011AA)
    CL Item
    Other (OTHER)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Pelvis (PELVIS)
    C12767 (NCI Thesaurus)
    C0030797 (UMLS 2011AA)
    CL Item
    Peripheral Vascular System (Peripheral Vascular)
    C0225806 (NCI Metathesaurus)
    CL Item
    Psychologic (PSYCHOLOGIC)
    CL Item
    Pulmonary (Pulmonary)
    C13304 (NCI Thesaurus)
    C2709248 (UMLS 2011AA)
    CL Item
    Rectal (Rectal)
    C25224 (NCI Thesaurus)
    C0205052 (UMLS 2011AA)
    CL Item
    Renal (Renal)
    C25225 (NCI Thesaurus)
    C0022646 (UMLS 2011AA)
    CL Item
    Reproductive History (Reproductive History)
    C17655 (NCI Thesaurus)
    C0206076 (UMLS 2011AA)
    CL Item
    Respiratory (RESPIRATORY)
    C25656 (NCI Thesaurus)
    C0521346 (UMLS 2011AA)
    CL Item
    Spleen (Spleen)
    C12432 (NCI Thesaurus)
    C0037993 (UMLS 2011AA)
    CL Item
    Substance Abuse/dependency (Substance abuse/Dependency)
    CL Item
    Transfusion History (Transfusion History)
    C30142 (NCI Thesaurus)
    C1519604 (UMLS 2011AA)
    CL Item
    Urinary (URINARY)
    C25711 (NCI Thesaurus)
    C1524119 (UMLS 2011AA)
    MedicalHistoryDescription
    Item
    Medical History Description
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25401 (NCI Thesaurus Property)
    C0205161 (UMLS 2011AA Property)
    C18772 (NCI Thesaurus Property)
    C0262926 (UMLS 2011AA Property)
    C25261 (NCI Thesaurus ObjectClass)
    C0205476 (UMLS 2011AA ObjectClass)
    Item Group
    Comments
    NoteDate
    Item
    Note Date
    date
    C25164 (NCI Thesaurus Property)
    C0011008 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C1317574 (NCI Metathesaurus ObjectClass)
    ResearchCommentsText
    Item
    Research Comments Text
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
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