ID

5619

Descrizione

A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2 Radiation Therapy and Stereotactic Radiosurgery With or Without Temozolomide or Erlotinib in Treating Patients With Brain Metastases Secondary to Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D81B5AB0-2D5B-616A-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D81B5AB0-2D5B-616A-E034-0003BA12F5E7

Keywords

versioni (4)
  1. 19/09/12 19/09/12 -
  2. 11/08/14 11/08/14 - Martin Dugas
  3. 09/01/15 09/01/15 - Martin Dugas
  4. 09/01/15 09/01/15 - Martin Dugas
Caricato su

11 agosto 2014

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00096265 Demographic - A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2 - 2277657v3.0

Inglese

No Instruction available.

1 moduli  
  1. StudyEvent: A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2
    1. No Instruction available.
Header
Descrizione

Header

[RTOG Study No.]
Descrizione

ProtocolRTOGIdentifierNumber

Tipo di dati

text

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

Case#

Tipo di dati

text

Institution
Descrizione

InstitutionName

Tipo di dati

text

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

InstitutionIdentifierNumber

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participant's Initials
Descrizione

PatientInitialsName

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Participant's I.D. No.
Descrizione

PatientRadiationTherapyOncologyGroupIdentifierNumber

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Module 1
Descrizione

Module 1

Date Completed
Descrizione

FormOriginalCompleteDate

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25604
UMLS 2011AA Property
C0205313
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
If this is a revised or corrected form, indicate by checking box.
Descrizione

DataAmendedInd-3

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Module 2
Descrizione

Module 2

Who completed this form? (check one box)
Descrizione

Whocompletedthisform?

Tipo di dati

text

Other, specify
Descrizione

PatientRaceSpecify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
Descrizione

PatientRaceCategory

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
Descrizione

PatientRaceCategory

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Highest school grade completed (Check one box)
Descrizione

Highestschoolgradecompleted

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C16529
UMLS 2011AA Property
C0013622
NCI Thesaurus Property
C25525
UMLS 2011AA Property
C1522410
Other, specify
Descrizione

Other,specify(highestschoolgradecompleted)

Tipo di dati

text

Religion during childhood (check one box)
Descrizione

PersonPediatricReligionName

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C39299
UMLS 2011AA Property
C0231335
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus Property
C17085
UMLS 2011AA Property
C0035039
Other, specify
Descrizione

ReligionduringchildhoodOther,specify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Marital status (check one box)
Descrizione

Maritalstatus

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Where were you born? (check one box Check the box of the country where you were born.)
Descrizione

Wherewereyouborn?

Tipo di dati

text

Other country, specify
Descrizione

Othercountry,specify(whereyouwereborn)

Tipo di dati

text

Where did you live the longest (check one box)
Descrizione

Wheredidyoulivethelongest

Tipo di dati

text

specify the 2 letter State code, eg NY
Descrizione

USA,specifythe2letterStatecode,egNY

Tipo di dati

text

specify the 2 letter State code, eg NY
Descrizione

USA,specifythe2letterStatecode,egNY

Tipo di dati

text

Other country, specify
Descrizione

Wheredidyoulivethelongest,othercountry,specify

Tipo di dati

text

Smoked at least 100 cigarette (5 packs) during lifetime
Descrizione

Smoking history

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1519384
NCI Thesaurus Property
C20989
NCI Thesaurus ObjectClass
C29719
Age began smoking cigarettes
Descrizione

PatientInitialCigaretteSmokingAgeYearCount

Tipo di dati

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property
C18270
UMLS 2011AA Property
C0700219
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Number of years smoked cigarettes
Descrizione

Numberofyearssmokedcigarettes

Tipo di dati

text

Average number of cigarettes smoked per day
Descrizione

Averagenumberofcigarettessmokedperday

Tipo di dati

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
If quit, age stopped smoking completely
Descrizione

PatientSmokingCessationAgeYear

Tipo di dati

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Metathesaurus Property
C0085134
If you have had any of the illness listed below, please check yes for those that apply. (check = Yes 2)
Descrizione

Ifyouhavehadanyoftheillnesslistedbelow,pleasecheckyesforthosethatapply.

Tipo di dati

text

Specify other
Descrizione

Specifyother(illness)

Tipo di dati

text

Family History
Descrizione

Family History

Brothers
Descrizione

Brothers

Tipo di dati

text

Sisters
Descrizione

Sisters

Tipo di dati

text

Sons
Descrizione

Sons

Tipo di dati

text

Daughters
Descrizione

Daughters

Tipo di dati

text

Are you adopted?
Descrizione

PatientAdoptedInd-3

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25290
UMLS 2011AA Property
C0425382
Blood relative with cancer
Descrizione

Bloodrelativewithcancer

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Age when first cancer diagnosed
Descrizione

PersonFirstCancerDiagnosisAgeYearCount

Tipo di dati

double

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C9305
UMLS 2011AA Property
C0006826
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus Property
C25150
UMLS 2011AA Property
C0001779
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Type of Cancer
Descrizione

TypeofCancer

Tipo di dati

text

Specify
Descrizione

specify(othercancers)

Tipo di dati

text

Have you ever heard of Cancer Prevention Trials?
Descrizione

CancerPreventionTrialKnowledgeDocumentedInd-2

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
NCI Thesaurus Property
C25356
UMLS 2011AA Property
C1301725
NCI Metathesaurus Property
C0376554
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
Descrizione

CancerPreventionTrialParticipationScale

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
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No Instruction available.

1 moduli
  1. StudyEvent: A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Header
Item
[RTOG Study No.]
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL.1
Code List
[RTOG Study No.]
CL Item
RTOG Study 0320 (RTOG Study 0320)
Case#
Item
Case #
text
InstitutionName
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InstitutionIdentifierNumber
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Participant's Initials
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientRadiationTherapyOncologyGroupIdentifierNumber
Item
Participant's I.D. No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Module 1
FormOriginalCompleteDate
Item
Date Completed
date
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
DataAmendedInd-3
Item
If this is a revised or corrected form, indicate by checking box.
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
Module 2
Item
Who completed this form? (check one box)
text
CL.2
Code List
Who completed this form? (check one box)
CL Item
Self (Self)
C25200 (NCI Thesaurus)
C0036588 (UMLS 2011AA)
CL Item
Staff (Staff)
CL Item
Other Person (Other person)
CL Item
Not Applicable, No Items Completed (Not applicable, no items completed)
PatientRaceSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
Item
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.4
Code List
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White, not Hispanic origin)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
CL Item
Hispanic (Hispanic)
CL Item
Black, not Hispanic origin (Black, not Hispanic origin)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands (Native Hawaiian or other Pacific Islander)
CL Item
A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment (Native American/Alaskan Nation)
CL Item
Patient Is Unsure Of Their Race (Unknown/I prefer not to answer)
Item
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.4
Code List
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White, not Hispanic origin)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
CL Item
Hispanic (Hispanic)
CL Item
Black, not Hispanic origin (Black, not Hispanic origin)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands (Native Hawaiian or other Pacific Islander)
CL Item
A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment (Native American/Alaskan Nation)
CL Item
Patient Is Unsure Of Their Race (Unknown/I prefer not to answer)
Item
Highest school grade completed (Check one box)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property)
C1522410 (UMLS 2011AA Property)
CL.5
Code List
Highest school grade completed (Check one box)
CL Item
8th Or Less (8th or less)
CL Item
9 - 11th Grade (9-11th Grade)
CL Item
High School Graduate / Ged (High school graduate/GED)
CL Item
Vocational / Technical School (Vocational/technical school)
CL Item
Bachelor's Degree (Associate degree/some college)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
CL Item
Bachelor's Degree (Bachelor's degree)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
CL Item
Advanced Degree (Advanced degree)
CL Item
Other, Specify (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Other,specify(highestschoolgradecompleted)
Item
Other, specify
text
Item
Religion during childhood (check one box)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C17085 (NCI Thesaurus Property)
C0035039 (UMLS 2011AA Property)
CL.6
Code List
Religion during childhood (check one box)
CL Item
Protestant (Protestant)
CL Item
Catholic (Catholic)
CL Item
Jewish (Jewish)
C0178443 (NCI Metathesaurus)
CL Item
Morman/latter Day Saints (Morman/Latter Day Saints)
CL Item
Muslim / Islam (Muslim/Islam)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Other, Specify (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
ReligionduringchildhoodOther,specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Marital status (check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.7
Code List
Marital status (check one box)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
CL Item
Single (Single)
CL Item
Divorced/separated (Divorced/Separated)
CL Item
Living As Married (Living as married)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Item
Where were you born? (check one box Check the box of the country where you were born.)
text
CL.8
Code List
Where were you born? (check one box Check the box of the country where you were born.)
CL Item
Usa, Specify The 2 Letter State Code, Eg Ny (USA)
CL Item
Other Country, Specify (Other country)
Othercountry,specify(whereyouwereborn)
Item
Other country, specify
text
Item
Where did you live the longest (check one box)
text
CL.9
Code List
Where did you live the longest (check one box)
CL Item
Usa, Specify The 2 Letter State Code, Eg Ny (USA)
CL Item
Other Country, Specify (Other country)
USA,specifythe2letterStatecode,egNY
Item
specify the 2 letter State code, eg NY
text
USA,specifythe2letterStatecode,egNY
Item
specify the 2 letter State code, eg NY
text
Wheredidyoulivethelongest,othercountry,specify
Item
Other country, specify
text
Item
Smoked at least 100 cigarette (5 packs) during lifetime
text
C25180 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C20989 (NCI Thesaurus Property)
C29719 (NCI Thesaurus ObjectClass)
CL.10
Code List
Smoked at least 100 cigarette (5 packs) during lifetime
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, But Quit (Yes, but quit)
CL Item
Yes, Currently Smoke (Yes, currently smoke)
PatientInitialCigaretteSmokingAgeYearCount
Item
Age began smoking cigarettes
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property)
C0700219 (UMLS 2011AA Property)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Numberofyearssmokedcigarettes
Item
Number of years smoked cigarettes
text
Averagenumberofcigarettessmokedperday
Item
Average number of cigarettes smoked per day
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientSmokingCessationAgeYear
Item
If quit, age stopped smoking completely
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C0085134 (NCI Metathesaurus Property)
Item
If you have had any of the illness listed below, please check yes for those that apply. (check = Yes 2)
text
CL.11
Code List
If you have had any of the illness listed below, please check yes for those that apply. (check = Yes 2)
CL Item
Heart Problems (Heart problems)
CL Item
Lung Problems (Lung problems)
CL Item
High Blood Pressure (High blood pressure)
CL Item
Bleeding Problems (Bleeding problems)
CL Item
Circulation Problems (Circulation problems)
CL Item
Liver Problems (Liver problems)
CL Item
Diabetes Or Sugar In Urine (Diabetes or sugar in urine)
CL Item
Kidney/urine Problems (Kidney/urine problems)
CL Item
Stroke (Stroke)
CL Item
Thyroid Problems (Thyroid problems)
CL Item
Seizure (Seizure)
C2962 (NCI Thesaurus)
C0036572 (UMLS 2011AA)
CL Item
Hiv/aids (HIV/AIDS)
CL Item
Frequent Infections (Frequent infections)
CL Item
Psychological Problems (Psychological problems)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Specifyother(illness)
Item
Specify other
text
Item Group
Family History
Brothers
Item
Brothers
text
Sisters
Item
Sisters
text
Sons
Item
Sons
text
Daughters
Item
Daughters
text
Item
Are you adopted?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25290 (NCI Thesaurus Property)
C0425382 (UMLS 2011AA Property)
CL.12
Code List
Are you adopted?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Blood relative with cancer
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.13
Code List
Blood relative with cancer
CL Item
Father (Father)
C25174 (NCI Thesaurus)
C0015671 (UMLS 2011AA)
CL Item
Mother (Mother)
C25189 (NCI Thesaurus)
C0026591 (UMLS 2011AA)
CL Item
Brother #1 (Brother #1)
CL Item
Brother #2 (Brother #2)
CL Item
Brother #3 (Brother #3)
CL Item
Brother #4 (Brother #4)
CL Item
Sister #1 (Sister #1)
CL Item
Sister #2 (Sister #2)
CL Item
Sister #3 (Sister #3)
CL Item
Sister #4 (Sister #4)
CL Item
Child #1 (Child #1)
CL Item
Child #2 (Child #2)
CL Item
Child #3 (Child #3)
CL Item
Child #4 (Child #4)
PersonFirstCancerDiagnosisAgeYearCount
Item
Age when first cancer diagnosed
double
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS 2011AA Property)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item
Type of Cancer
text
CL.14
Code List
Type of Cancer
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Prostate (Prostate)
C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)
CL Item
Head & Neck (Head & Neck)
CL Item
Non Melanoma Skin (Non Melanoma Skin)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
specify(othercancers)
Item
Specify
text
Item
Have you ever heard of Cancer Prevention Trials?
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
C0376554 (NCI Metathesaurus Property)
CL.15
Code List
Have you ever heard of Cancer Prevention Trials?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
CL.16
Code List
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
CL Item
1- Never Would Consider (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
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