ID
7066
Beschrijving
E1105 Quality of Life Assessment Form First-Line Chemotherapy and Trastuzumab With or Without Bevacizumab in Treating Patients With Metastatic Breast Cancer That Overexpresses HER-2/NEU Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1736308A-3F51-3856-E044-0003BA3F9857
Link
Trefwoorden
Versies (3)
- 26-08-12 26-08-12 -
- 08-01-15 08-01-15 - Martin Dugas
- 25-03-15 25-03-15 - Martin Dugas
Geüploaded op
8 januari 2015
DOI
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Licentie
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00520975 Quality of Life - E1105 Quality of Life Assessment Form - 2491906v1.0
INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).
- StudyEvent: E1105 Quality of Life Assessment Form
Beschrijving
Unnamed2
Beschrijving
Protocol Number ECOG
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C3274381
- NCI Thesaurus ObjectClass
- C25320
- UMLS CUI-2
- C1512162
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25491
Beschrijving
Patient Initials
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2986440
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25536
Beschrijving
Patient ID ECOG
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2348585
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C1512162
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25491
Beschrijving
Study Number Participating Group
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C3274381
- NCI Thesaurus ObjectClass
- C25320
- UMLS CUI-2
- C2347449
- NCI Thesaurus Property
- C25608
- NCI Thesaurus Property-2
- C25364
Beschrijving
Institution Name
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C25454
- UMLS CUI-1
- C1301943
- NCI Thesaurus ObjectClass-2
- C21541
- NCI Thesaurus Property
- C25364
- NCI Thesaurus ValueDomain
- C25191
- NCI Thesaurus ValueDomain-2
- C21541
Beschrijving
Trial subject ID Participating Group
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2348585
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C2347449
- NCI Thesaurus Property
- C25608
- NCI Thesaurus Property-2
- C25364
Beschrijving
Unnamed Module 4
Beschrijving
Cycle number
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C2045829
- NCI Thesaurus Property
- C25214
- NCI Thesaurus Property-2
- C25616
- NCI Thesaurus ObjectClass
- C15368
Beschrijving
Cycle number
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C2045829
- NCI Thesaurus Property
- C25214
- NCI Thesaurus Property-2
- C25616
- NCI Thesaurus ObjectClass
- C15368
Beschrijving
Unnamed4
Beschrijving
Data amended
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C0680532
- NCI Thesaurus ObjectClass
- C25474
- NCI Thesaurus Property
- C25416
Beschrijving
Data amended date
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0680532
- NCI Thesaurus ObjectClass
- C25474
- UMLS CUI-2
- C0011008
- NCI Thesaurus Property
- C25416
- NCI Thesaurus ValueDomain-2
- C25367
Beschrijving
Unnamed6
Beschrijving
FatigueAssessmentResponseScale
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ObjectClass
- C20989
- UMLS 2011AA ObjectClass
- C0031809
- NCI Thesaurus Property
- C25755
- UMLS 2011AA Property
- C0871261
- NCI Thesaurus ObjectClass-2
- C3036
- UMLS 2011AA ObjectClass-2
- C0015672
Beschrijving
PainAssessmentResponseScale
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ObjectClass
- C20989
- UMLS 2011AA ObjectClass
- C0031809
- NCI Thesaurus Property
- C25755
- UMLS 2011AA Property
- C0871261
- NCI Thesaurus ObjectClass-2
- C3303
- UMLS 2011AA ObjectClass-2
- C0030193
Beschrijving
NauseaAssessmentResponseScale
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ObjectClass
- C20989
- UMLS 2011AA ObjectClass
- C0031809
- NCI Thesaurus Property
- C25755
- UMLS 2011AA Property
- C0871261
- NCI Thesaurus ObjectClass-2
- C3258
- UMLS 2011AA ObjectClass-2
- C0027497
Beschrijving
SignificantPatientLocalizedPainAssessmentQualityofLifeScale
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus ObjectClass-2
- C41130
- UMLS 2011AA ObjectClass-2
- C0750502
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Metathesaurus Property
- CL232212
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ValueDomain-2
- C17047
- UMLS 2011AA ValueDomain-2
- C0518214
Beschrijving
DyspneaAssessmentResponseScale
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ObjectClass
- C20989
- UMLS 2011AA ObjectClass
- C0031809
- NCI Thesaurus Property
- C25755
- UMLS 2011AA Property
- C0871261
- NCI Thesaurus ObjectClass-2
- C2998
- UMLS 2011AA ObjectClass-2
- C0013404
Beschrijving
WorryPatientDeteriorationAssessmentQualityofLifeScale
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Metathesaurus ObjectClass
- C0233481
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus Property-2
- C25751
- UMLS 2011AA Property-2
- C0868945
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ValueDomain-2
- C17047
- UMLS 2011AA ValueDomain-2
- C0518214
Beschrijving
PatientQualityofLifeAssessmentQualityofLifeScale
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C17047
- UMLS 2011AA Property
- C0518214
- NCI Thesaurus Property-2
- C20989
- UMLS 2011AA Property-2
- C0031809
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ValueDomain-2
- C17047
- UMLS 2011AA ValueDomain-2
- C0518214
Beschrijving
FamilyAssessmentRequiredResponseType
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C20989
- UMLS 2011AA ObjectClass
- C0031809
- NCI Thesaurus Property
- C25755
- UMLS 2011AA Property
- C0871261
Beschrijving
ToxicityAssessmentResponseScale
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C20989
- UMLS 2011AA ObjectClass
- C0031809
- NCI Thesaurus ObjectClass-2
- C27990
- UMLS 2011AA ObjectClass-2
- C0600688
- NCI Thesaurus Property
- C25755
- UMLS 2011AA Property
- C0871261
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ValueDomain-2
- C17047
- UMLS 2011AA ValueDomain-2
- C0518214
Beschrijving
NeurotoxicityPatientParaesthesiaHandAssessmentQualityofLifeScale
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus ObjectClass-2
- C27961
- UMLS 2011AA ObjectClass-2
- C0235032
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Metathesaurus Property
- C0239836
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ValueDomain-2
- C17047
- UMLS 2011AA ValueDomain-2
- C0518214
Beschrijving
NeurotoxicityPatientParaesthesiaFootAssessmentQualityofLifeScale
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus ObjectClass-2
- C27961
- UMLS 2011AA ObjectClass-2
- C0235032
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Metathesaurus Property
- CL108114
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ValueDomain-2
- C17047
- UMLS 2011AA ValueDomain-2
- C0518214
Beschrijving
NeurotoxicityPatientHandDiscomfortAssessmentQualityofLifeScale
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus ObjectClass-2
- C27961
- UMLS 2011AA ObjectClass-2
- C0235032
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus Property-2
- C32712
- UMLS 2011AA Property-2
- C0018563
- NCI Metathesaurus Property
- CL047845
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ValueDomain-2
- C17047
- UMLS 2011AA ValueDomain-2
- C0518214
Beschrijving
NeurotoxicityPatientFootDiscomfortAssessmentQualityofLifeScale
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus ObjectClass-2
- C27961
- UMLS 2011AA ObjectClass-2
- C0235032
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Metathesaurus Property
- CL050515
- NCI Thesaurus ValueDomain
- C25664
- UMLS 2011AA ValueDomain
- C0349674
- NCI Thesaurus ValueDomain-2
- C17047
- UMLS 2011AA ValueDomain-2
- C0518214
Similar models
INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).
- StudyEvent: E1105 Quality of Life Assessment Form
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2045829 (UMLS CUI-1)
C25214 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
C2045829 (UMLS CUI-1)
C25214 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C3036 (NCI Thesaurus ObjectClass-2)
C0015672 (UMLS 2011AA ObjectClass-2)
C91213 (NCI Thesaurus-2)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C3303 (NCI Thesaurus ObjectClass-2)
C0030193 (UMLS 2011AA ObjectClass-2)
C91213 (NCI Thesaurus-2)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C3258 (NCI Thesaurus ObjectClass-2)
C0027497 (UMLS 2011AA ObjectClass-2)
C91213 (NCI Thesaurus-2)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0030705 (UMLS 2011AA ObjectClass)
C41130 (NCI Thesaurus ObjectClass-2)
C0750502 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL232212 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C2998 (NCI Thesaurus ObjectClass-2)
C0013404 (UMLS 2011AA ObjectClass-2)
C91213 (NCI Thesaurus-2)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0030705 (UMLS 2011AA ObjectClass)
C0233481 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25751 (NCI Thesaurus Property-2)
C0868945 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0030705 (UMLS 2011AA ObjectClass)
C17047 (NCI Thesaurus Property)
C0518214 (UMLS 2011AA Property)
C20989 (NCI Thesaurus Property-2)
C0031809 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C0205448 (UMLS 2011AA)
C0031809 (UMLS 2011AA ObjectClass)
C27990 (NCI Thesaurus ObjectClass-2)
C0600688 (UMLS 2011AA ObjectClass-2)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C0235032 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0239836 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C0235032 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL108114 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C0235032 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C32712 (NCI Thesaurus Property-2)
C0018563 (UMLS 2011AA Property-2)
CL047845 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C0235032 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL050515 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
C91216 (NCI Thesaurus-2)
C91217 (NCI Thesaurus-2)