ID

6175

Descrição

Quality of Life Module for Trial 24-02 (Form 24-QLM) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA5B57-DF0D-6356-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA5B57-DF0D-6356-E034-0003BA12F5E7

Palavras-chave

Versões (1)
  1. 15/12/2014 15/12/2014 - Martin Dugas
Transferido a

15 de dezembro de 2014

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Quality of Life - Quality of Life Module for Trial 24-02 (Form 24-QLM) - 2073726v3.0

Inglês

QUALITY OF LIFE MODULE FOR TRIAL 24-02 (Form 24-QLM) Patient Instructions: We would like to know how strongly you are affected by your illness and treatment. Please answer the following questions by placing a vertical mark on the line depending on how you assess yourself. (See the example on the Quality of Life Core Questionnaire.) Your information will be treated as strictly confidential. Thank you for replying!

1 Formulários  
Within The Last Two Weeks, How Severe Have The Following Problems Been?
Descrição

Within The Last Two Weeks, How Severe Have The Following Problems Been?

Being irritable
Descrição

Being irritable

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0022107
Sweats (including night sweats including night)
Descrição

Sweats (including night sweats including night)

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0038990
Vaginal discharge
Descrição

Vaginal discharge

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0227791
Vaginal dryness
Descrição

Vaginal dryness

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
Vaginal itching / irritation
Descrição

Vaginal itching or irritation

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
Sleep disturbance
Descrição

Sleep disturbance

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
Feeling dizzy
Descrição

Feeling dizzy

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0012833
Headaches
Descrição

Headache Present QOL Severity Status

Tipo de dados

integer

Alias
NCI Thesaurus Property
C25626
NCI Thesaurus ObjectClass
C34661
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0018681
Bone or joint pain
Descrição

Bone or joint pain

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C0151825
UMLS CUI-2
C0003862
Troubled by weight gain
Descrição

Troubled by weight gain

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
Loss of sexual interest
Descrição

Loss of sexual interest

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
Overall, how much are you bothered by any treatment related difficulties?
Descrição

Overall, how much are you bothered by any treatment related difficulties?

Tipo de dados

integer

Have you been sexually active during the past six months?
Descrição

Have you been sexually active during the past six months?

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C25180
Did you have difficulties in becoming aroused?
Descrição

Did you have difficulties in becoming aroused?

Tipo de dados

integer

Alias
NCI Thesaurus ValueDomain
C25688
Ccrr Module For Quality Of Life Module For Trial 24-02 (form 24-qlm)
Descrição

Ccrr Module For Quality Of Life Module For Trial 24-02 (form 24-qlm)

Patient ID Number (Study No.)
Descrição

Patient ID Number (Study No.)

Tipo de dados

text

Alias
UMLS CUI-1
C1549740
Patient Initials (f m fl sl)
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
UMLS CUI-1
C2986440
Patient's Date of Birth (day)
Descrição

Patient's Date of Birth (day)

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25275
UMLS CUI-1
C0421451
Participating Center/Affiliate
Descrição

Participating Center/Affiliate

Tipo de dados

text

Center Code
Descrição

Center Code

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS CUI-1
C0565990
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Similar models

QUALITY OF LIFE MODULE FOR TRIAL 24-02 (Form 24-QLM) Patient Instructions: We would like to know how strongly you are affected by your illness and treatment. Please answer the following questions by placing a vertical mark on the line depending on how you assess yourself. (See the example on the Quality of Life Core Questionnaire.) Your information will be treated as strictly confidential. Thank you for replying!

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Within The Last Two Weeks, How Severe Have The Following Problems Been?
Item
Being irritable
integer
C25688 (NCI Thesaurus ValueDomain)
C0022107 (UMLS CUI-1)
CL.1
Code List
Being irritable
CL Item
None (0)
CL Item
Severe (1)
Item
Sweats (including night sweats including night)
integer
C25688 (NCI Thesaurus ValueDomain)
C0038990 (UMLS CUI-1)
CL.2
Code List
Sweats (including night sweats including night)
CL Item
None (0)
CL Item
Severe (1)
Item
Vaginal discharge
integer
C25688 (NCI Thesaurus ValueDomain)
C0227791 (UMLS CUI-1)
CL.3
Code List
Vaginal discharge
CL Item
None (0)
CL Item
Severe (1)
Item
Vaginal dryness
integer
C25688 (NCI Thesaurus ValueDomain)
CL.4
Code List
Vaginal dryness
CL Item
None (0)
CL Item
Severe (1)
Item
Vaginal itching / irritation
integer
C25688 (NCI Thesaurus ValueDomain)
CL.5
Code List
Vaginal itching / irritation
CL Item
None (0)
CL Item
Severe (1)
Item
Sleep disturbance
integer
C25688 (NCI Thesaurus ValueDomain)
CL.6
Code List
Sleep disturbance
CL Item
None (0)
CL Item
Severe (1)
Item
Feeling dizzy
integer
C25688 (NCI Thesaurus ValueDomain)
C0012833 (UMLS CUI-1)
CL.7
Code List
Feeling dizzy
CL Item
None (0)
CL Item
Severe (1)
Item
Headaches
integer
C25626 (NCI Thesaurus Property)
C34661 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0018681 (UMLS CUI-1)
CL.8
Code List
Headaches
CL Item
None (0)
CL Item
Severe (1)
Item
Bone or joint pain
integer
C25688 (NCI Thesaurus ValueDomain)
C0151825 (UMLS CUI-1)
C0003862 (UMLS CUI-2)
CL.9
Code List
Bone or joint pain
CL Item
None (0)
CL Item
Severe (1)
Item
Troubled by weight gain
integer
C25688 (NCI Thesaurus ValueDomain)
CL.10
Code List
Troubled by weight gain
CL Item
None (0)
CL Item
Severe (1)
Item
Loss of sexual interest
integer
C25688 (NCI Thesaurus ValueDomain)
CL.11
Code List
Loss of sexual interest
CL Item
None (0)
CL Item
Severe (1)
Item
Overall, how much are you bothered by any treatment related difficulties?
integer
CL.12
Code List
Overall, how much are you bothered by any treatment related difficulties?
CL Item
Not At All (0)
CL Item
Severely (1)
Sexually active past 6 months
Item
Have you been sexually active during the past six months?
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
Did you have difficulties in becoming aroused?
integer
C25688 (NCI Thesaurus ValueDomain)
CL.14
Code List
Did you have difficulties in becoming aroused?
CL Item
None (0)
CL Item
Severe (1)
Item Group
Ccrr Module For Quality Of Life Module For Trial 24-02 (form 24-qlm)
Patient ID
Item
Patient ID Number (Study No.)
text
C1549740 (UMLS CUI-1)
Patient Initials
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
Patient Birth Date
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0421451 (UMLS CUI-1)
Main Member Institution or Affiliate
Item
Participating Center/Affiliate
text
Center Code
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0565990 (UMLS CUI-1)
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