ID

7088

Descrição

The Division of Cancer Prevention's baseline medical/surgical history case report form (CRF) template. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5199EB1D-38BD-6DDA-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5199EB1D-38BD-6DDA-E044-0003BA3F9857

Palavras-chave

  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Transferido a

9 de janeiro de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy

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On-Study - Baseline Medical/Surgical History - 2764025v1.0

No Instruction available.

  1. StudyEvent: Baseline Medical/Surgical History
    1. No Instruction available.
Screening
Descrição

Screening

DCP Protocol #
Descrição

Protocol ID NCI

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1513882
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C19202
Institution Code
Descrição

NationalCancerInstituteInstituteCode

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participant ID
Descrição

ParticipantIdentifier

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25364
UMLS 2011AA ValueDomain
C0600091
Visit Type
Descrição

VisitTypeText

Tipo de dados

text

Alias
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Visit Date
Descrição

VisitDate

Tipo de dados

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C25716
UMLS 2011AA ObjectClass
C0545082
Baseline Medical/surgical History
Descrição

Baseline Medical/surgical History

Check here if all body systems are normal
Descrição

BaselineMedicalHistoryBodySystemNormalIndicator

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25213
UMLS 2011AA ObjectClass
C1442488
NCI Thesaurus ObjectClass-2
C49603
UMLS 2011AA ObjectClass-2
C1704706
NCI Thesaurus Property
C12919
UMLS 2011AA Property
C0460002
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ValueDomain-2
C13041
UMLS 2011AA ValueDomain-2
C1268086
NCI Thesaurus ValueDomain-3
C14165
UMLS 2011AA ValueDomain-3
C0205307
NCI Thesaurus ValueDomain-4
C64916
UMLS 2011AA ValueDomain-4
C0444868
NCI Thesaurus ValueDomain-5
C25700
UMLS 2011AA ValueDomain-5
C0449913
Body System
Descrição

BodySystemType

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C13041
UMLS 2011AA ObjectClass
C1268086
NCI Thesaurus Property
C25700
UMLS 2011AA Property
C0449913
Body System
Descrição

BodySystemIndicator

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C13041
UMLS 2011AA ObjectClass
C1268086
NCI Thesaurus Property
C25700
UMLS 2011AA Property
C0449913
NCI Metathesaurus ValueDomain
C0021212
Comment (Required if Abnormal) (Provide condition/diagnosis)
Descrição

AbnormalCommentText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25393
UMLS 2011AA ObjectClass
C0282411
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Does the participant have any allergies?
Descrição

Allergyindicator

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C3114
UMLS 2011AA ObjectClass
C0020517
NCI Thesaurus Property
C54625
UMLS 2011AA Property
C2004062
If Yes, specify
Descrição

AllergyHistorySpecifyText

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C3114
UMLS 2011AA ObjectClass
C0020517
NCI Thesaurus Property
C54625
UMLS 2011AA Property
C2004062
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C25704
UMLS 2011AA ValueDomain-2
C1527021
NCI Thesaurus ValueDomain-3
C3114
UMLS 2011AA ValueDomain-3
C0020517
Dcp Template Footer
Descrição

Dcp Template Footer

Protocol Title
Descrição

Protocol Title

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986303
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C42774
Protocol Version
Descrição

Protocol Version

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C2985700
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C25364
Protocol Date
Descrição

Protocol Version Date

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2985700
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C0011008
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain-2
C25367
Page #
Descrição

PageNumber

Tipo de dados

float

Alias
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Metathesaurus ObjectClass
C0439643
Total Page Number
Descrição

CaseReportFormTotalPageNumber

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25337
UMLS 2011AA Property
C0237753
NCI Thesaurus Property-2
C25304
UMLS 2011AA Property-2
C0439810
NCI Thesaurus Property-3
C42783
UMLS 2011AA Property-3
C1704732
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
DCP Template Version
Descrição

DCPTemplateVersionText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Metathesaurus ObjectClass
C0728990
NCI Thesaurus Property
C25714
UMLS 2011AA Property
C0333052

Similar models

No Instruction available.

  1. StudyEvent: Baseline Medical/Surgical History
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Screening
Protocol ID NCI
Item
DCP Protocol #
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1513882 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C19202 (NCI Thesaurus Property-2)
NationalCancerInstituteInstituteCode
Item
Institution Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ParticipantIdentifier
Item
Participant ID
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
VisitTypeText
Item
Visit Type
text
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
VisitDate
Item
Visit Date
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)
Item Group
Baseline Medical/surgical History
Item
Check here if all body systems are normal
text
C25213 (NCI Thesaurus ObjectClass)
C1442488 (UMLS 2011AA ObjectClass)
C49603 (NCI Thesaurus ObjectClass-2)
C1704706 (UMLS 2011AA ObjectClass-2)
C12919 (NCI Thesaurus Property)
C0460002 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C13041 (NCI Thesaurus ValueDomain-2)
C1268086 (UMLS 2011AA ValueDomain-2)
C14165 (NCI Thesaurus ValueDomain-3)
C0205307 (UMLS 2011AA ValueDomain-3)
C64916 (NCI Thesaurus ValueDomain-4)
C0444868 (UMLS 2011AA ValueDomain-4)
C25700 (NCI Thesaurus ValueDomain-5)
C0449913 (UMLS 2011AA ValueDomain-5)
Code List
Check here if all body systems are normal
CL Item
All Normal (All Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
C64916 (NCI Thesaurus-3)
C0444868 (UMLS 2011AA-4)
Item
Body System
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C13041 (NCI Thesaurus ObjectClass)
C1268086 (UMLS 2011AA ObjectClass)
C25700 (NCI Thesaurus Property)
C0449913 (UMLS 2011AA Property)
Code List
Body System
CL Item
H/e/e/n/t (H/E/E/N/T)
CL Item
Neck (NECK)
C13063 (NCI Thesaurus)
C0027530 (UMLS 2011AA)
CL Item
Respiratory (RESPIRATORY)
C25656 (NCI Thesaurus)
C0521346 (UMLS 2011AA)
CL Item
Cardiovascular (CARDIOVASCULAR)
C25292 (NCI Thesaurus)
C0007226 (UMLS 2011AA)
CL Item
Gastrointestinal (GASTROINTESTINAL)
C13359 (NCI Thesaurus)
C0521362 (UMLS 2011AA)
CL Item
Musculoskeletal (MUSCULOSKELETAL)
C25348 (NCI Thesaurus)
C0497254 (UMLS 2011AA)
CL Item
Dermatologic (DERMATOLOGIC)
C0205489 (NCI Metathesaurus)
CL Item
Hematopoietic/lymph (HEMATOPOIETIC/LYMPH)
C12745 (NCI Thesaurus)
C0024204 (UMLS 2011AA)
CL Item
Endocrine/metabolic (ENDOCRINE/METABOLIC)
CL Item
Genitourinary (Genitourinary)
CL Item
Breasts (BREASTS)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Neurologic (NEUROLOGIC)
C25262 (NCI Thesaurus)
C0205494 (UMLS 2011AA)
Item
Body System
text
C13041 (NCI Thesaurus ObjectClass)
C1268086 (UMLS 2011AA ObjectClass)
C25700 (NCI Thesaurus Property)
C0449913 (UMLS 2011AA Property)
C0021212 (NCI Metathesaurus ValueDomain)
Code List
Body System
CL Item
Abnormal (Abnormal)
C25401 (NCI Thesaurus)
C0205161 (UMLS 2011AA)
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
CL Item
Not Assessed (Not Assessed)
C25594 (NCI Thesaurus)
C1518422 (UMLS 2011AA)
C25217 (NCI Thesaurus-3)
C1516048 (UMLS 2011AA-4)
AbnormalCommentText
Item
Comment (Required if Abnormal) (Provide condition/diagnosis)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25393 (NCI Thesaurus ObjectClass)
C0282411 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Allergyindicator
Item
Does the participant have any allergies?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C3114 (NCI Thesaurus ObjectClass)
C0020517 (UMLS 2011AA ObjectClass)
C54625 (NCI Thesaurus Property)
C2004062 (UMLS 2011AA Property)
AllergyHistorySpecifyText
Item
If Yes, specify
text
C3114 (NCI Thesaurus ObjectClass)
C0020517 (UMLS 2011AA ObjectClass)
C54625 (NCI Thesaurus Property)
C2004062 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25704 (NCI Thesaurus ValueDomain-2)
C1527021 (UMLS 2011AA ValueDomain-2)
C3114 (NCI Thesaurus ValueDomain-3)
C0020517 (UMLS 2011AA ValueDomain-3)
Item Group
Dcp Template Footer
Protocol Title
Item
Protocol Title
text
C25191 (NCI Thesaurus ValueDomain)
C2986303 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C42774 (NCI Thesaurus Property)
Protocol Version
Item
Protocol Version
text
C25704 (NCI Thesaurus ValueDomain)
C2985700 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Protocol Version Date
Item
Protocol Date
date
C25164 (NCI Thesaurus ValueDomain)
C2985700 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
PageNumber
Item
Page #
float
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0439643 (NCI Metathesaurus ObjectClass)
CaseReportFormTotalPageNumber
Item
Total Page Number
text
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25304 (NCI Thesaurus Property-2)
C0439810 (UMLS 2011AA Property-2)
C42783 (NCI Thesaurus Property-3)
C1704732 (UMLS 2011AA Property-3)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
DCPTemplateVersionText
Item
DCP Template Version
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C0728990 (NCI Metathesaurus ObjectClass)
C25714 (NCI Thesaurus Property)
C0333052 (UMLS 2011AA Property)

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