ID

43366

Descripción

Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer NCT00024102 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Palabras clave

Versiones (3)
  1. 18/12/14 18/12/14 - Martin Dugas
  2. 20/3/15 20/3/15 - Martin Dugas
  3. 20/9/21 20/9/21 -
Subido en

20 de septiembre de 2021

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer (NCT00024102)

Inglés

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 formularios  
Header
Descripción

Header

CALGB Form
Descripción

CALGB Form

Tipo de datos

text

Alias
UMLS CUI-1
C3262252
UMLS CUI-2
C1516238
CALGB Study No
Descripción

CALGBStudyNo

Tipo de datos

text

Alias
UMLS CUI-1
C3274381
UMLS CUI-2
C1516238
CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

Date Completed (Medicine)
Descripción

DateCompleted

Tipo de datos

date

Amended data?
Descripción

Amended data?

Tipo de datos

boolean

Alias
UMLS CUI-1
C0680532
Patient's Name
Descripción

Patient'sName

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroup

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Descripción

PatientHospitalNumber

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Adjunct

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientNo.

Tipo de datos

text

Responsible CRA
Descripción

ResponsibleCRA

Tipo de datos

text

Assessment Number (1. Your General Health)
Descripción

AssessmentNumber

Tipo de datos

float

Patient characteristics
Descripción

Patient characteristics

Alias
UMLS CUI-1
C0815172
Other cancers or leukemia
Descripción

Othercancersorleukemia

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Other cancers or leukemia (b.)
Descripción

How much does it interfere with your activities: Other cancers or leukemia (b.)

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Arthritis, rheumatism, or other connective tissue disorders (b.)
Descripción

Arthritis,rheumatism,orotherconnectivetissuedisorders

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
Descripción

Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
Glaucoma (c.)
Descripción

Glaucoma (c.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0017601
How much does it interfere with your activities: Glaucoma (d.)
Descripción

Howmuchdoesitinterferewithyouractivities:Glaucoma

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Emphysema or Chronic Bronchitis (d.)
Descripción

Emphysema or Chronic Bronchitis (d.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
Descripción

Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
High Blood Pressure (e.)
Descripción

HighBloodPressure

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0020538
How much does it interfere with your activities: High Blood Pressure (f.)
Descripción

Howmuchdoesitinterferewithyouractivities:HighBloodPressure

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
Heart disease (f.)
Descripción

Heartdisease

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0018799
How much does it interfere with your activities: Heart disease (g.)
Descripción

Howmuchdoesitinterferewithyouractivities:Heartdisease

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Circulation trouble in arms or legs (g.)
Descripción

Circulationtroubleinarmsorlegs

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0728936
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
Descripción

Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Diabetes (h.)
Descripción

Diabetes (h.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0011849
How much does it interfere with your activities: Diabetes (i.)
Descripción

Howmuchdoesitinterferewithyouractivities:Diabetes

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
Stomach or intestinal disorders (i.)
Descripción

Stomach or intestinal disorders (i.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
Descripción

Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
Osteoporosis (j.)
Descripción

Osteoporosis (j.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0029456
How much does it interfere with your activities: Osteoporosis (k.)
Descripción

Howmuchdoesitinterferewithyouractivities:Osteoporosis

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
Chronic Liver or Kidney Disease (k.)
Descripción

Chronic Liver or Kidney Disease (k.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Descripción

How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
Stroke (l.)
Descripción

Stroke (l.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0038454
How much does it interfere with your activities: Stroke (m.)
Descripción

How much does it interfere with your activities: Stroke (m.)

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
Depression (m.)
Descripción

Depression (m.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0011581
How much does it interfere with your activities: Depression
Descripción

How much does it interfere with your activities: Depression

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
How is your eyesight (with glasses or contacts)? (mark one with an X)
Descripción

Howisyoureyesight(withglassesorcontacts)?

Tipo de datos

text

Alias
UMLS CUI-1
C0042812
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
Descripción

Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
Descripción

How is your hearing (with a hearing aid, if needed)? (mark one with an X)

Tipo de datos

text

Alias
UMLS CUI-1
C0018767
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Descripción

If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
Descripción

Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?

Tipo de datos

text

Yes, specify (other physical problems or illnesses at the present time that seriously affect your health) (If Yes)
Descripción

Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)

Tipo de datos

text

how much does this interfere with your activities? (mark one with an X)
Descripción

how much does this interfere with your activities? (mark one with an X)

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
Descripción

Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?

Tipo de datos

text

During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
Descripción

Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?

Tipo de datos

text

How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Descripción

How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)

Tipo de datos

text

Counseling
Descripción

Counseling

Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
Descripción

Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0849496
What type of counseling or treatment did you receive? (mark all that apply with an X)
Descripción

What type of counseling or treatment did you receive? (mark all that apply with an X)

Tipo de datos

text

Other, specify (type of counseling or treatment received) (8c.)
Descripción

Other, specify (type of counseling or treatment received) (8c.)

Tipo de datos

text

Check any of these services that you are still receiving (mark all that apply with an X)
Descripción

Check any of these services that you are still receiving (mark all that apply with an X)

Tipo de datos

text

Other, specify (services that you are still receiving) (Only For ALL FOLLOW-UP INTERVIEWS: Questions 9-10)
Descripción

Other,specify(servicesthatyouarestillreceiving)

Tipo de datos

text

Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
Descripción

Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0849496
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Descripción

What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)

Tipo de datos

text

Other, specify (services that you are still receiving; follow-up)
Descripción

Other,specify(servicesthatyouarestillreceiving;follow-up)

Tipo de datos

text

Medication
Descripción

Medication

Alias
UMLS CUI-1
C0013227
Medicine to treat nausea and/or vomiting
Descripción

Medicine to treat nausea and/or vomiting

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
Medicine to treat diarrhea
Descripción

Medicine to treat diarrhea

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0003292
Medicine to reduce feeling very tired [fatigue]
Descripción

Medicinetoreducefeelingverytired[fatigue]

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine to reduce swelling in hands or feet
Descripción

Medicinetoreduceswellinginhandsorfeet

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine or cream to treat mouth sores
Descripción

Medicineorcreamtotreatmouthsores

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Pain medicine for hands or feet
Descripción

Painmedicineforhandsorfeet

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Descripción

Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
Other, specify
Descripción

Other,specify

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Other, specify (medication to treat any physical problems you have had from your cancer treatment)
Descripción

Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)

Tipo de datos

text

Arthritis medicine (If Taken, How Often?)
Descripción

Arthritismedicine

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Arthritis medicine (b.)
Descripción

If Taken, How Often: Arthritis medicine (b.)

Tipo de datos

text

Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Descripción

Prescriptionpainkiller

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Descripción

If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)

Tipo de datos

text

Alias
UMLS CUI-1
C0002771
UMLS CUI-2
C0439603
Over-the counter pain killers (c.)
Descripción

Over-thecounterpainkillers

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
Descripción

If Taken, How Often: Over-the counter pain killers (other than for arthritis)

Tipo de datos

text

High blood pressure medicine (d.)
Descripción

Highbloodpressuremedicine

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: High blood pressure medicine (e.)
Descripción

If Taken, How Often: High blood pressure medicine (e.)

Tipo de datos

text

Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
Descripción

Pillstomakeyoulosewaterorsalt

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Pills to make you lose water or salt (f.)
Descripción

If Taken, How Often: Pills to make you lose water or salt (f.)

Tipo de datos

text

Digoxin pills for the heart (Lanoxin)
Descripción

Digoxinpillsfortheheart

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Descripción

If Taken, How Often: Digoxin pills for the heart (Lanoxin)

Tipo de datos

text

Nitroglycerin for chest pain (tablets or patches)
Descripción

Nitroglycerinforchestpain

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Descripción

If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)

Tipo de datos

text

Blood thinner medicine (anticoagulants)
Descripción

Bloodthinnermedicine

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Blood thinner medicine (anticoagulants)
Descripción

If Taken, How Often: Blood thinner medicine (anticoagulants)

Tipo de datos

text

Medicine to improve circulation (i.)
Descripción

Medicinetoimprovecirculation

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Medicine to improve circulation (j.)
Descripción

If Taken, How Often: Medicine to improve circulation (j.)

Tipo de datos

text

Insulin injections for diabetes (j.)
Descripción

Insulin injections for diabetes (j.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0199782
If Taken, How Often: Insulin injections for diabetes (k.)
Descripción

If Taken, How Often: Insulin injections for diabetes (k.)

Tipo de datos

text

Pills for diabetes (k.)
Descripción

Pillsfordiabetes

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Pills for diabetes (l.)
Descripción

If Taken, How Often: Pills for diabetes (l.)

Tipo de datos

text

Ulcer medicine (l.)
Descripción

Ulcermedicine

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Ulcer medicine (m.)
Descripción

If Taken, How Often: Ulcer medicine (m.)

Tipo de datos

text

Asthma medicines (m.)
Descripción

Asthma medicines (m.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282556
If Taken, How Often: Asthma medicines (n.)
Descripción

If Taken, How Often: Asthma medicines (n.)

Tipo de datos

text

Seizure medicines (like Dilantin)
Descripción

Seizuremedicines

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Seizure medicines (like Dilantin)
Descripción

If Taken, How Often: Seizure medicines (like Dilantin)

Tipo de datos

text

Thyroid pills (If Taken, How Often?)
Descripción

Thyroidpills

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Thyroid pills (p.)
Descripción

If Taken, How Often: Thyroid pills (p.)

Tipo de datos

text

Cortisone pills or injections (p.)
Descripción

Cortisonepillsorinjections

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0010137
If Taken, How Often: Cortisone pills or injections (q.)
Descripción

If Taken, How Often: Cortisone pills or injections (q.)

Tipo de datos

text

Antibiotics (q.)
Descripción

Antibiotics (q.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0003232
If Taken, How Often: Antibiotics (r.)
Descripción

If Taken, How Often: Antibiotics (r.)

Tipo de datos

text

Tranquilizers or medicine for your nerves (r.)
Descripción

Tranquilizersormedicineforyournerves

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0040614
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Descripción

If Taken, How Often: Tranquilizers or medicine for your nerves (s.)

Tipo de datos

text

Prescription sleeping pills (s.)
Descripción

Prescriptionsleepingpills

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0599396
If Taken, How Often: Prescription sleeping pills (t.)
Descripción

If Taken, How Often: Prescription sleeping pills (t.)

Tipo de datos

text

Over-the-counter pills to help you sleep (t.)
Descripción

Over-the-counterpillstohelpyousleep

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Descripción

If Taken, How Often: Over-the-counter pills to help you sleep (u.)

Tipo de datos

text

Hormones (male or female)
Descripción

Hormones (male or female)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0019932
If Taken, How Often: Hormones (v.)
Descripción

If Taken, How Often: Hormones (v.)

Tipo de datos

text

Allergy medicines (v.)
Descripción

Allergy medicines (v.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282555
If Taken, How Often: Allergy medicines (w.)
Descripción

If Taken, How Often: Allergy medicines (w.)

Tipo de datos

text

Laxatives (w.)
Descripción

Laxatives (w.)

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282090
If Taken, How Often: Laxatives (x.)
Descripción

If Taken, How Often: Laxatives (x.)

Tipo de datos

text

Eye drops for glaucoma (x.)
Descripción

Eyedropsforglaucoma

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Eye drops for glaucoma (y.)
Descripción

If Taken, How Often: Eye drops for glaucoma (y.)

Tipo de datos

text

Calcium tablets (y.)
Descripción

Calciumtablets

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Calcium tablets (z.)
Descripción

If Taken, How Often: Calcium tablets (z.)

Tipo de datos

text

Vitamins and/or minerals (other than calcium)
Descripción

Vitaminsand/orminerals

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Descripción

If Taken, How Often: Vitamins and/or minerals (other than calcium)

Tipo de datos

text

Herbal medicines (aa.)
Descripción

Herbalmedicines

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0242388
If Taken, How Often: Herbal medicines (12.)
Descripción

If Taken, How Often: Herbal medicines (12.)

Tipo de datos

text

Have you taken any other medicines in the past month?
Descripción

Have you taken any other medicines in the past month?

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1522602
Name of Medicine
Descripción

NameofMedicine

Tipo de datos

text

If Taken, How Often?
Descripción

If Taken, How Often?

Tipo de datos

text

Alias
UMLS CUI-1
C3476109
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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
CALGBForm
Item
CALGB Form
text
C3262252 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGBStudyNo
Item
CALGB Study No
text
C3274381 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Amendeddata
Item
Amended data?
boolean
C0680532 (UMLS CUI-1)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1. Your General Health)
float
Item Group
C0815172 (UMLS CUI-1)
Other cancers or leukemia
Item
Other cancers or leukemia
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Other cancers or leukemia (b.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
How much does it interfere with your activities: Other cancers or leukemia (b.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Arthritis or rheumatism
Item
Arthritis, rheumatism, or other connective tissue disorders (b.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Glaucoma
Item
Glaucoma (c.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0017601 (UMLS CUI-1)
Item
How much does it interfere with your activities: Glaucoma (d.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
How much does it interfere with your activities: Glaucoma (d.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Emphysema or ChronicBronchitis
Item
Emphysema or Chronic Bronchitis (d.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
High Blood Pressure
Item
High Blood Pressure (e.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0020538 (UMLS CUI-1)
Item
How much does it interfere with your activities: High Blood Pressure (f.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: High Blood Pressure (f.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Heartdisease
Item
Heart disease (f.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0018799 (UMLS CUI-1)
Item
How much does it interfere with your activities: Heart disease (g.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
How much does it interfere with your activities: Heart disease (g.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Circulation disorder
Item
Circulation trouble in arms or legs (g.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0728936 (UMLS CUI-1)
Item
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Diabetes
Item
Diabetes (h.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0011849 (UMLS CUI-1)
Item
How much does it interfere with your activities: Diabetes (i.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Diabetes (i.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Stomach or intestinal disorders
Item
Stomach or intestinal disorders (i.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Osteoporosis
Item
Osteoporosis (j.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0029456 (UMLS CUI-1)
Item
How much does it interfere with your activities: Osteoporosis (k.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Osteoporosis (k.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Chronic Liver or Kidney Disease
Item
Chronic Liver or Kidney Disease (k.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Stroke
Item
Stroke (l.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0038454 (UMLS CUI-1)
Item
How much does it interfere with your activities: Stroke (m.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Stroke (m.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Depression
Item
Depression (m.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0011581 (UMLS CUI-1)
Item
How much does it interfere with your activities: Depression
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Depression
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
How is your eyesight (with glasses or contacts)? (mark one with an X)
text
C0042812 (UMLS CUI-1)
CL.28
Code List
How is your eyesight (with glasses or contacts)? (mark one with an X)
CL Item
Excellent (Excellent)
C1961136 (UMLS CUI-1)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
C0205170 (UMLS CUI-1)
CL Item
Fair (Fair)
C2911689 (UMLS CUI-1)
CL Item
Poor (Poor)
C2700379 (UMLS CUI-1)
CL Item
Totally Blind (Totally blind)
C0456909 (UMLS CUI-1)
Item
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
text
C0018767 (UMLS CUI-1)
CL.30
Code List
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
CL Item
Excellent (Excellent)
C1961136 (UMLS CUI-1)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
C0205170 (UMLS CUI-1)
CL Item
Fair (Fair)
C2911689 (UMLS CUI-1)
CL Item
Poor (Poor)
C2700379 (UMLS CUI-1)
CL Item
Totally Deaf (Totally deaf)
C1547302 (UMLS CUI-1)
Item
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
text
CL.32
Code List
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Specify (Yes, specify)
Other physical problems or illnesses
Item
Yes, specify (other physical problems or illnesses at the present time that seriously affect your health) (If Yes)
text
Item
how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
text
CL.34
Code List
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 To 2 (1 to 2)
CL Item
3 To 5 (3 to 5)
CL Item
6 To 9 (6 to 9)
CL Item
10 To 14 (10 to 14)
CL Item
15 Or More (15 or more)
CL Item
Don't Know (Don't know)
Item
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
text
CL.35
Code List
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
A Week Or Less (A week or less)
CL Item
More Than A Week, But Less Than A Month (More than a week, but less than a month)
CL Item
One To Two Months (One to two months)
CL Item
Three Months (Three months)
Item
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
text
CL.36
Code List
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 To 2 (1 to 2)
CL Item
3 To 5 (3 to 5)
CL Item
6 To 9 (6 to 9)
CL Item
10 To 14 (10 to 14)
CL Item
15 Or More (15 or more)
CL Item
Don't Know (Don't know)
Item Group
problem related counselling
Item
Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0849496 (UMLS CUI-1)
Item
What type of counseling or treatment did you receive? (mark all that apply with an X)
text
CL.38
Code List
What type of counseling or treatment did you receive? (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other, specify
Item
Other, specify (type of counseling or treatment received) (8c.)
text
Item
Check any of these services that you are still receiving (mark all that apply with an X)
text
CL.38
Code List
Check any of these services that you are still receiving (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other,specify(servicesthatyouarestillreceiving)
Item
Other, specify (services that you are still receiving) (Only For ALL FOLLOW-UP INTERVIEWS: Questions 9-10)
text
problem related counselling
Item
Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0849496 (UMLS CUI-1)
Item
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
text
CL.38
Code List
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other services
Item
Other, specify (services that you are still receiving; follow-up)
text
Item Group
C0013227 (UMLS CUI-1)
Medicine to treat nausea and/or vomiting
Item
Medicine to treat nausea and/or vomiting
boolean
C25180 (NCI Thesaurus ValueDomain)
Medicine to treat diarrhea
Item
Medicine to treat diarrhea
boolean
C25180 (NCI Thesaurus ValueDomain)
C0003292 (UMLS CUI-1)
Medicinetoreducefeelingverytired[fatigue]
Item
Medicine to reduce feeling very tired [fatigue]
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medicinetoreduceswellinginhandsorfeet
Item
Medicine to reduce swelling in hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medicineorcreamtotreatmouthsores
Item
Medicine or cream to treat mouth sores
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Painmedicineforhandsorfeet
Item
Pain medicine for hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medication regarding skin changes
Item
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
Other,specify
Item
Other, specify
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Other medication
Item
Other, specify (medication to treat any physical problems you have had from your cancer treatment)
text
Arthritismedicine
Item
Arthritis medicine (If Taken, How Often?)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Arthritis medicine (b.)
text
CL.80
Code List
If Taken, How Often: Arthritis medicine (b.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Prescriptionpainkiller
Item
Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
text
C0002771 (UMLS CUI-1)
C0439603 (UMLS CUI-2)
CL.80
Code List
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Over-thecounterpainkillers
Item
Over-the counter pain killers (c.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
text
CL.80
Code List
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Highbloodpressuremedicine
Item
High blood pressure medicine (d.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: High blood pressure medicine (e.)
text
CL.80
Code List
If Taken, How Often: High blood pressure medicine (e.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Pillstomakeyoulosewaterorsalt
Item
Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Pills to make you lose water or salt (f.)
text
CL.80
Code List
If Taken, How Often: Pills to make you lose water or salt (f.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Digoxinpillsfortheheart
Item
Digoxin pills for the heart (Lanoxin)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
text
CL.80
Code List
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Nitroglycerinforchestpain
Item
Nitroglycerin for chest pain (tablets or patches)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
text
CL.80
Code List
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Bloodthinnermedicine
Item
Blood thinner medicine (anticoagulants)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Blood thinner medicine (anticoagulants)
text
CL.80
Code List
If Taken, How Often: Blood thinner medicine (anticoagulants)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Medicinetoimprovecirculation
Item
Medicine to improve circulation (i.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Medicine to improve circulation (j.)
text
CL.80
Code List
If Taken, How Often: Medicine to improve circulation (j.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Insulin injections for diabetes
Item
Insulin injections for diabetes (j.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0199782 (UMLS CUI-1)
Item
If Taken, How Often: Insulin injections for diabetes (k.)
text
CL.80
Code List
If Taken, How Often: Insulin injections for diabetes (k.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Pillsfordiabetes
Item
Pills for diabetes (k.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Pills for diabetes (l.)
text
CL.80
Code List
If Taken, How Often: Pills for diabetes (l.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Ulcermedicine
Item
Ulcer medicine (l.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Ulcer medicine (m.)
text
CL.80
Code List
If Taken, How Often: Ulcer medicine (m.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Asthma medicines
Item
Asthma medicines (m.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282556 (UMLS CUI-1)
Item
If Taken, How Often: Asthma medicines (n.)
text
CL.80
Code List
If Taken, How Often: Asthma medicines (n.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Seizuremedicines
Item
Seizure medicines (like Dilantin)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Seizure medicines (like Dilantin)
text
CL.80
Code List
If Taken, How Often: Seizure medicines (like Dilantin)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Thyroidpills
Item
Thyroid pills (If Taken, How Often?)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Thyroid pills (p.)
text
CL.80
Code List
If Taken, How Often: Thyroid pills (p.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Cortisone
Item
Cortisone pills or injections (p.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0010137 (UMLS CUI-1)
Item
If Taken, How Often: Cortisone pills or injections (q.)
text
CL.80
Code List
If Taken, How Often: Cortisone pills or injections (q.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Antibiotics
Item
Antibiotics (q.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0003232 (UMLS CUI-1)
Item
If Taken, How Often: Antibiotics (r.)
text
CL.80
Code List
If Taken, How Often: Antibiotics (r.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Tranquilizer
Item
Tranquilizers or medicine for your nerves (r.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0040614 (UMLS CUI-1)
Item
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
text
CL.80
Code List
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Sleeping pills
Item
Prescription sleeping pills (s.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0599396 (UMLS CUI-1)
Item
If Taken, How Often: Prescription sleeping pills (t.)
text
CL.80
Code List
If Taken, How Often: Prescription sleeping pills (t.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Over-the-counterpillstohelpyousleep
Item
Over-the-counter pills to help you sleep (t.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
text
CL.80
Code List
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Hormones
Item
Hormones (male or female)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0019932 (UMLS CUI-1)
Item
If Taken, How Often: Hormones (v.)
text
CL.80
Code List
If Taken, How Often: Hormones (v.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Allergy medicines
Item
Allergy medicines (v.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282555 (UMLS CUI-1)
Item
If Taken, How Often: Allergy medicines (w.)
text
CL.80
Code List
If Taken, How Often: Allergy medicines (w.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Laxatives
Item
Laxatives (w.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282090 (UMLS CUI-1)
Item
If Taken, How Often: Laxatives (x.)
text
CL.80
Code List
If Taken, How Often: Laxatives (x.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Eyedropsforglaucoma
Item
Eye drops for glaucoma (x.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Eye drops for glaucoma (y.)
text
CL.80
Code List
If Taken, How Often: Eye drops for glaucoma (y.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Calciumtablets
Item
Calcium tablets (y.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Calcium tablets (z.)
text
CL.80
Code List
If Taken, How Often: Calcium tablets (z.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Vitaminsand/orminerals
Item
Vitamins and/or minerals (other than calcium)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Vitamins and/or minerals (other than calcium)
text
CL.80
Code List
If Taken, How Often: Vitamins and/or minerals (other than calcium)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
Herbal medicine
Item
Herbal medicines (aa.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0242388 (UMLS CUI-1)
Item
If Taken, How Often: Herbal medicines (12.)
text
CL.80
Code List
If Taken, How Often: Herbal medicines (12.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
other medication past month
Item
Have you taken any other medicines in the past month?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS CUI-1)
NameofMedicine
Item
Name of Medicine
text
Item
If Taken, How Often?
text
C3476109 (UMLS CUI-1)
CL.80
Code List
If Taken, How Often?
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1720688 (UMLS CUI-1)
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