ID
693
Description
IBCSG Long Term Follow-Up Medication Form (18-LTF-M) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C7B-8540-E040-BB89AD4303DD
Link
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 6/20/17 6/20/17 - Martin Dugas
Uploaded on
August 26, 2012
DOI
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License
Creative Commons BY-NC 3.0
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Breast Cancer Follow-Up - IBCSG Long Term Follow-Up Medication Form (18-LTF-M) - 3108532v1.0
Instructions: This form is to be completed if the patient received bone active medication, non-steroidal, anti-inflammatory drug or extended adjuvant therapy during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done
- StudyEvent: IBCSG Long Term Follow-Up Medication Form (18-LTF-M)
Description
Long Term Follow-up Medication
Description
MedicationOsteoporosisAdministeredIndicator
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
- NCI Thesaurus Property
- C3298
- UMLS 2011AA Property
- C0029456
- NCI Thesaurus ObjectClass
- C459
- UMLS 2011AA ObjectClass
- C0013227
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
MedicationOsteoporosisAdministeredType
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus Property
- C3298
- UMLS 2011AA Property
- C0029456
- NCI Thesaurus ObjectClass
- C459
- UMLS 2011AA ObjectClass
- C0013227
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
MedicationOsteoporosisAdministeredSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus Property
- C3298
- UMLS 2011AA Property
- C0029456
- NCI Thesaurus ObjectClass
- C459
- UMLS 2011AA ObjectClass
- C0013227
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
ConcomitantMedicationCorticosteroidAdministeredIndicator
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C459
- UMLS 2011AA ObjectClass
- C0013227
- NCI Thesaurus ObjectClass
- C25730
- UMLS 2011AA ObjectClass
- C0521115
- NCI Thesaurus Property
- C2322
- UMLS 2011AA Property
- C0001617
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
ConcomitantMedicationOtherCorticosteroidAdministeredSpecify
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C459
- UMLS 2011AA ObjectClass
- C0013227
- NCI Thesaurus ObjectClass
- C25730
- UMLS 2011AA ObjectClass
- C0521115
- NCI Thesaurus Property
- C17649
- UMLS 2011AA Property
- C0205394
- NCI Thesaurus Property
- C2322
- UMLS 2011AA Property
- C0001617
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
Description
PatientNonsteroidalAntiinflammatoryDrugRegularUsePersonalMedicalHistoryIndicator
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C18772
- UMLS 2011AA Property
- C0262926
- NCI Thesaurus Property
- C257
- UMLS 2011AA Property
- C0003211
- NCI Thesaurus Property
- C25340
- UMLS 2011AA Property
- C0457083
- NCI Thesaurus Property
- C25647
- UMLS 2011AA Property
- C0205272
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
NonsteroidalAntiinflammatoryDrugMedicationReportingPeriodSpecify
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C459
- UMLS 2011AA ObjectClass
- C0013227
- NCI Thesaurus ObjectClass
- C257
- UMLS 2011AA ObjectClass
- C0003211
- NCI Thesaurus Property
- C25616
- UMLS 2011AA Property
- C1948053
- NCI Thesaurus Property
- C25651
- UMLS 2011AA Property
- C0700287
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
Description
AdjuvantHormonalTherapyAdministeredIndicator
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C2140
- UMLS 2011AA ObjectClass
- C0001552
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
AdjuvantHormoneTherapyBeginDate
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C2140
- UMLS 2011AA ObjectClass
- C0001552
- NCI Thesaurus Property
- C25431
- UMLS 2011AA Property
- C0439659
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ValueDomain
- C25431
- UMLS 2011AA ValueDomain
- C0439659
Description
AdjuvantHormoneTherapyEndDate
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C2140
- UMLS 2011AA ObjectClass
- C0001552
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
- NCI Thesaurus Property
- C25496
- UMLS 2011AA Property
- C2746065
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
AdjuvantHormonalTherapyAdministeredType
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C2140
- UMLS 2011AA ObjectClass
- C0001552
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
NewAdjuvantHormoneTherapyAdministeredSpecify
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25586
- UMLS 2011AA ObjectClass
- C0205314
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C2140
- UMLS 2011AA ObjectClass
- C0001552
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
Description
PriorTreatmentDiscontinuedReason
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS 2011AA ValueDomain
- C0392360
- NCI Thesaurus ObjectClass
- C25629
- UMLS 2011AA ObjectClass
- C0332152
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25484
- UMLS 2011AA Property
- C1444662
Description
Off-treatmentReasonSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C25601
- UMLS 2011AA ObjectClass
- C1518544
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Description
Footer Module
Description
InvestigatorDesignatedSignatureText
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
- NCI Thesaurus Property
- C25479
- UMLS 2011AA Property
- C1524084
Description
InvestigatorSignatureDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ValueDomain
- C25367
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
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Instructions: This form is to be completed if the patient received bone active medication, non-steroidal, anti-inflammatory drug or extended adjuvant therapy during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done
- StudyEvent: IBCSG Long Term Follow-Up Medication Form (18-LTF-M)
C0237753 (UMLS 2011AA ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25385 (NCI Thesaurus Property)
C0809949 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
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C1507394 (UMLS 2011AA ObjectClass)
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C1512890 (UMLS 2011AA Property)
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C0034656 (UMLS 2011AA Property)
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C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
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C0600091 (UMLS 2011AA Property)
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C1298908 (UMLS 2011AA)
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C0029456 (UMLS 2011AA Property)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0012544 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C1521902 (UMLS 2011AA ValueDomain)
C3298 (NCI Thesaurus Property)
C0029456 (UMLS 2011AA Property)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C2322 (NCI Thesaurus Property)
C0001617 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass)
C0521115 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C2322 (NCI Thesaurus Property)
C0001617 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C257 (NCI Thesaurus Property)
C0003211 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C25647 (NCI Thesaurus Property)
C0205272 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0013227 (UMLS 2011AA ObjectClass)
C257 (NCI Thesaurus ObjectClass)
C0003211 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property)
C0700287 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass)
C0001552 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0279025 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass)
C0001552 (UMLS 2011AA ObjectClass)
C25431 (NCI Thesaurus Property)
C0439659 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C0279025 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass)
C0001552 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property)
C2746065 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass)
C0001552 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0246421 (UMLS 2011AA)
C0039286 (UMLS 2011AA)
C0290882 (UMLS 2011AA)
C0060116 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C0205314 (UMLS 2011AA ObjectClass)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass)
C0001552 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
C1709536 (UMLS 2011AA)
C0877248 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
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C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
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C0678257 (UMLS 2011AA Property)
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C0035173 (UMLS 2011AA ObjectClass)
C25479 (NCI Thesaurus Property)
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