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ID
5694
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
Keywords
Versions (6)
- 9/20/12 9/20/12 -
- 8/11/14 8/11/14 - Martin Dugas
- 8/11/14 8/11/14 - Martin Dugas
- 8/11/14 8/11/14 - Martin Dugas
- 1/9/15 1/9/15 - Martin Dugas
- 9/20/21 9/20/21 -
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August 11, 2014
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License
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
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- StudyEvent: Curative Treatment for Head and Neck Cancer - On-Study Form
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- StudyEvent: Curative Treatment for Head and Neck Cancer - On-Study Form
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
ProtocolCoordinatingIdentifierNumber
Item
Coordinating Group Protocol No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CoordinatingGroupIdentifierCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus ObjectClass)
C0700114 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0805701 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus ObjectClass)
C0700114 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProtocolTitleName
Item
Protocol Title
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA Property)
C1547383 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA Property)
PatientCoordinatingIdentifierNumber
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CombinedInstitutionName
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
PatientParticipatingIdentifierNumber
Item
Other Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
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)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0805701 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient 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)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
ResponsiblePersonName
Item
Person Completing Form
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Are data amended? (If data are amended, please circle in red when using paper form)
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)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Performance Status (check one)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C25491 (NCI Thesaurus ValueDomain)
C1512162 (UMLS 2011AA ValueDomain)
C20641 (NCI Thesaurus ObjectClass)
C1518965 (UMLS 2011AA ObjectClass)
C0349674 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C25491 (NCI Thesaurus ValueDomain)
C1512162 (UMLS 2011AA ValueDomain)
C20641 (NCI Thesaurus ObjectClass)
C1518965 (UMLS 2011AA ObjectClass)
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)
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)
C0011900 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
C0006826 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
Item
Primary Site
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property)
C0205225 (UMLS 2011AA Property)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property)
C0205225 (UMLS 2011AA Property)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
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)
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)
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)
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)
C0027423 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
PrimaryDiseaseSiteSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
Item
Is this a second primary in the upper aero-digestive tract (Note: includes patients with second primary when curative treatment is planned.)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus Property)
C0205436 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus Property)
C0205436 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
Is this a second primary in the upper aero-digestive tract (Note: includes patients with second primary when curative treatment is planned.)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
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)
C0205543 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C0018704 (UMLS 2011AA ObjectClass)
C25642 (NCI Thesaurus ObjectClass)
C0205543 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
Item
Histologic Type (values continue on next page)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)
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)
C0206623 (UMLS 2011AA)
CL Item
Adenocarcinoma (Adenocarcinoma)
C2852 (NCI Thesaurus)
C0001418 (UMLS 2011AA)
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)
C0206694 (UMLS 2011AA)
CL Item
Adenoid Cystic Carcinoma (Adenoid cystic carcinoma)
C2970 (NCI Thesaurus)
C0010606 (UMLS 2011AA)
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)
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)
C0206703 (UMLS 2011AA)
CL Item
Small Cell Carcinoma (Small cell carcinoma)
C3915 (NCI Thesaurus)
C0262584 (UMLS 2011AA)
C0262584 (UMLS 2011AA)
CL Item
Salivary Duct Carcinoma (Salivary duct carcinoma)
C5904 (NCI Thesaurus)
C1301194 (UMLS 2011AA)
C1301194 (UMLS 2011AA)
CL Item
Carcinoid Tumor (Carcinoid tumor)
C2915 (NCI Thesaurus)
C0007095 (UMLS 2011AA)
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)
C0205698 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
TumorHistologicCategorySpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
C1521902 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
Item
Histologic Grade (check highest grade)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)
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)
C0460004 (UMLS 2011AA ObjectClass)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25728 (NCI Thesaurus Property)
C0475455 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25728 (NCI Thesaurus Property)
C0475455 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
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)
C0460004 (UMLS 2011AA ObjectClass)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property)
C0456532 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property)
C0456532 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
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)
C0460004 (UMLS 2011AA ObjectClass)
C25228 (NCI Thesaurus Property)
C0205090 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property)
C0456532 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25228 (NCI Thesaurus Property)
C0205090 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property)
C0456532 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
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)
C0460004 (UMLS 2011AA ObjectClass)
C25229 (NCI Thesaurus Property)
C0205091 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property)
C0456532 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25229 (NCI Thesaurus Property)
C0205091 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property)
C0456532 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
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)
C0460004 (UMLS 2011AA ObjectClass)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25727 (NCI Thesaurus Property)
C0456533 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25727 (NCI Thesaurus Property)
C0456533 (UMLS 2011AA Property)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
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
Item
Does the patient have a chronic disease
text
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)
C0205191 (UMLS 2011AA ObjectClass)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass)
C0205191 (UMLS 2011AA ObjectClass)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
C0205191 (UMLS 2011AA ObjectClass)
C0332307 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C14141 (NCI Thesaurus ObjectClass)
C0205191 (UMLS 2011AA ObjectClass)
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)
C0205191 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain)
C0205394 (UMLS 2011AA ValueDomain)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass)
C0205191 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain)
C0205394 (UMLS 2011AA ValueDomain)
Item
Weight Loss in Previous Six Months (check one)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3445 (NCI Thesaurus Property)
C0043096 (UMLS 2011AA Property)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3445 (NCI Thesaurus Property)
C0043096 (UMLS 2011AA Property)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
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)
C0332307 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
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)
C0439673 (UMLS 2011AA)
Item
Does the patient currently smoke
text
C38148 (NCI Thesaurus ValueDomain)
C3241966 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C17934 (NCI Thesaurus ObjectClass)
C0449865 (NCI Metathesaurus Property)
C3241966 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C17934 (NCI Thesaurus ObjectClass)
C0449865 (NCI Metathesaurus Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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)
C1608325 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C0449865 (NCI Metathesaurus Property)
C25473 (NCI Thesaurus ValueDomain)
C25515 (NCI Thesaurus ValueDomain)
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)
C0453997 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C25330 (NCI Thesaurus ValueDomain)
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)
C0332307 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
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)
C0439673 (UMLS 2011AA)
Item
Does the patient currently consume alcohol
text
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)
C0457083 (UMLS 2011AA Property)
C1512698 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
C0457083 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
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)
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)
C0332281 (UMLS 2011AA Property)
C1522602 (UMLS 2011AA ValueDomain)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25281 (NCI Thesaurus Property)
C0332281 (UMLS 2011AA Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
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)
C1444662 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
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)
C0011167 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass)
C0011167 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
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)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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)
C0011167 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass)
C0011167 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
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)
C0439673 (UMLS 2011AA)
Item
Does the patient currently have swallowing problems
text
C25518 (NCI Thesaurus ObjectClass)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass)
C0011167 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass)
C0011167 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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)
C0011167 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass)
C0011167 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
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)
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)
C1533734 (UMLS 2011AA Property)
C1512699 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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)
C1533734 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
C0332152 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
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)
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)
C1533734 (UMLS 2011AA Property)
C1512699 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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)
C1533734 (UMLS 2011AA Property)
C1512699 (UMLS 2011AA ValueDomain)
C25251 (NCI Thesaurus Property)
C0205225 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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)
C1512806 (UMLS 2011AA ValueDomain)
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)
C1512806 (UMLS 2011AA ValueDomain)
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)
C0450429 (UMLS 2011AA ValueDomain)
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)
C0450429 (UMLS 2011AA ValueDomain)
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)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C38025 (NCI Thesaurus ObjectClass)
C0037817 (UMLS 2011AA ObjectClass)
CL092952 (NCI Metathesaurus ObjectClass)
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)