ID

7136

Descrição

Head and Neck Cancers - Follow Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D49693D6-CE22-5E44-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D49693D6-CE22-5E44-E034-0003BA12F5E7

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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Follow-Up - Head and Neck Cancers - Follow Up Form - 2268620v3.0

No Instruction available.

  1. StudyEvent: Head and Neck Cancers - Follow Up Form
    1. No Instruction available.
Crf Header
Descrição

Crf Header

Coordinating Group Protocol No.
Descrição

Protocol ID Coordinating Group

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1711341
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Coordinating Group Code
Descrição

Coordinating Group Code

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS CUI-1
C1711341
NCI Thesaurus ObjectClass
C17005
UMLS CUI-2
C0805701
NCI Thesaurus ObjectClass-2
C25462
NCI Thesaurus Property
C25364
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
Patient Study ID
Descrição

Patient Study ID

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Institution/Affiliate
Descrição

Institution Name

Tipo de dados

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
Other Patient ID
Descrição

Trial subject ID Participating Group

Tipo de dados

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
Participating Group Code
Descrição

ParticipatingGroupIdentifierCode

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass-2
C17005
UMLS 2011AA ObjectClass-2
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Initials
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Head & Neck: Vital Status
Descrição

Head & Neck: Vital Status

Patient's Vital Status
Descrição

Patient Status

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS CUI-1
C3846084
NCI Thesaurus ValueDomain
C18003
NCI Thesaurus ValueDomain-2
C25688
NCI Thesaurus Property
C25717
Primary Cause of Death
Descrição

Primary Cause of Death

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS CUI-1
C0007465
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C28554
NCI Thesaurus ValueDomain-2
C25251
Describe cause of death
Descrição

Cause of Death, specify

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS CUI-1
C0007465
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1521902
NCI Thesaurus Property
C28554
Date of Last Contact or Death (mm dd yyyy)
Descrição

Date last contact

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS CUI-1
C0805839
NCI Thesaurus Property
C25461
NCI Thesaurus Property-2
C25551
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
Is the patient off study (and further follow-up evaluations will not be completed)
Descrição

Off-TreatmentStudyFollow-UpInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C16033
UMLS 2011AA Property
C1522577
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15206
UMLS 2011AA ObjectClass-2
C0008972
Off Study Reason (If yes,)
Descrição

Off-TreatmentStudyFollow-UpReason

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C16033
UMLS 2011AA Property
C1522577
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15206
UMLS 2011AA ObjectClass-2
C0008972
Other specify
Descrição

Off-TreatmentStudyFollow-UpSpecify

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C16033
UMLS 2011AA Property
C1522577
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15206
UMLS 2011AA ObjectClass-2
C0008972
Head & Neck: Disease Follow-up Status
Descrição

Head & Neck: Disease Follow-up Status

Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form?)
Descrição

Documented clinical assessment for this cancer

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1522577
NCI Thesaurus Property
C16033
UMLS CUI-2
C0006826
NCI Thesaurus ObjectClass
C9305
NCI Thesaurus Property-2
C25365
Date of Last Clinical Assessment (mm dd yyyy)
Descrição

Follow-Up Date

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C9305
UMLS CUI-1
C3694716
NCI Thesaurus Property
C16033
NCI Thesaurus Property-2
C25365
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
Head & Neck: Notice Of Progression
Descrição

Head & Neck: Notice Of Progression

Has the patient developed a first progression (or relapse) that has not been previously reported?
Descrição

DiseaseProgressionInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25331
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
Has the patient been diagnosed with first local-regional recurrence (or progression?)
Descrição

Neoplasm Recurrence, locoregional

Tipo de dados

boolean

Alias
NCI Thesaurus ObjectClass
C19987
UMLS CUI-1
C0027643
NCI Thesaurus Property
C25388
NCI Thesaurus Property-2
C25509
NCI Thesaurus Property-3
C15220
NCI Thesaurus ValueDomain
C38148
Site of First Local-Regional Progression (s mark all that apply)
Descrição

FirstProgressionLocal-RegionalSite

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus ObjectClass-2
C25509
UMLS 2011AA ObjectClass
C1279901
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25388
UMLS 2011AA Property-2
C1947913
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
Other specify
Descrição

FirstProgressionLocal-RegionalSiteSpecify

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus ObjectClass-2
C25509
UMLS 2011AA ObjectClass
C1279901
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25388
UMLS 2011AA Property-2
C1947913
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Date of First Local-Regional Progression (per protocol definition leave blank if distant relapse previously reported)
Descrição

Local-RegionalProgressionFirstDate

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus ObjectClass-2
C25388
UMLS 2011AA ObjectClass
C1947913
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property-2
C25275
UMLS 2011AA Property-2
C2745955
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25509
UMLS 2011AA ValueDomain-2
C1279901
Has the patient been diagnosed with first distant recurrence/progression?
Descrição

FirstProgressionDistantPresentInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ObjectClass
C19987
UMLS 2011AA ObjectClass
C0242656
NCI Thesaurus Property
C25321
UMLS 2011AA Property
C0443203
NCI Thesaurus Property-2
C25509
UMLS 2011AA Property-2
C1279901
NCI Thesaurus Property-3
C15220
UMLS 2011AA Property-3
C0011900
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Site of First Distant Progression (s mark all that apply)
Descrição

DistantProgressionFirstSite

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus ObjectClass-2
C25321
UMLS 2011AA ObjectClass
C0443203
NCI Thesaurus Property-2
C25509
UMLS 2011AA Property-2
C1279901
Other specify
Descrição

FirstProgressionDistantSiteSpecify

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus ObjectClass-2
C25509
UMLS 2011AA ObjectClass
C1279901
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25321
UMLS 2011AA Property-2
C0443203
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Date of First Distant Progression (leave blank if distant relapse previously reported)
Descrição

Date of Neoplasm distal recurrence

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0027627
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus ValueDomain-2
C25509
UMLS CUI-2
C0011008
NCI Thesaurus Property
C25275
Head & Neck: Notice Of New Primary
Descrição

Head & Neck: Notice Of New Primary

Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
Descrição

NewCancerDiagnosisInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25586
UMLS 2011AA ObjectClass
C0205314
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Is this a Second primary in the Upper Aero-digestive Tract? (If yes,)
Descrição

HeadandNeckTumorSecondOccurrenceInd-2

Tipo de dados

boolean

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass-2
C12418
UMLS 2011AA ObjectClass-2
C0460004
NCI Thesaurus Property
C25666
UMLS 2011AA Property
C0205436
NCI Thesaurus Property-2
C25275
UMLS 2011AA Property-2
C2745955
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Site of New Primary (If new primary site is AML/MDS, please submit NCI AML/MDS form.)
Descrição

NewCancerSiteText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25586
UMLS 2011AA ObjectClass
C0205314
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
Date of Diagnosis (If new primary site is AML/MDS, please submit NCI AML/MDS form.)
Descrição

NewCancerDiagnosisDate

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C25586
UMLS 2011AA ObjectClass
C0205314
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
Head & Neck: New Adverse Events
Descrição

Head & Neck: New Adverse Events

Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >=3), long term toxicity that has not been previously reported
Descrição

RTOGAdverseEventReportInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C19778
UMLS 2011AA ObjectClass
C1514695
NCI Thesaurus ObjectClass-2
C41331
UMLS 2011AA ObjectClass-2
C0877248
NCI Thesaurus Property
C25375
UMLS 2011AA Property
C0684224
CTC Adverse Event Term
Descrição

CommonToxicityCriteriaAdverseEventTermType

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C49704
UMLS 2011AA ObjectClass
C1516728
NCI Thesaurus Property
C45559
UMLS 2011AA Property
C1705313
CTC Adverse Event Grade
Descrição

CommonToxicityCriteriaAdverseEventGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C49704
UMLS 2011AA ObjectClass
C1516728
NCI Thesaurus ValueDomain
C18000
UMLS 2011AA ValueDomain
C0919553
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Head & Neck: Long-term Functional Assessment
Descrição

Head & Neck: Long-term Functional Assessment

Does the patient currently have swallowing problems?
Descrição

SwallowingFunctionCurrentDeficitInd-3

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25518
UMLS 2011AA ObjectClass
C0542341
NCI Thesaurus ObjectClass-2
C38028
UMLS 2011AA ObjectClass-2
C0011167
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus Property-2
C37940
UMLS 2011AA Property-2
C0011155
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
How long have swallowing problems been present? (If yes,)
Descrição

SwallowingFunctionCurrentDeficitDuration

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25518
UMLS 2011AA ObjectClass
C0542341
NCI Thesaurus ObjectClass-2
C38028
UMLS 2011AA ObjectClass-2
C0011167
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus Property-2
C37940
UMLS 2011AA Property-2
C0011155
NCI Thesaurus ValueDomain
C25330
UMLS 2011AA ValueDomain
C0449238
Does the patient currently require tube feeding?
Descrição

GavageCurrentAdministrationInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus ObjectClass
C73430
UMLS 2011AA ObjectClass
C0041281
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
Is patient dependent on tube feeding for >50% of nutritional support? (If yes,)
Descrição

GavagePrimaryAdministrationInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25251
UMLS 2011AA Property
C0205225
NCI Thesaurus ObjectClass
C73430
UMLS 2011AA ObjectClass
C0041281
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
Was a feeding tube inserted during this reporting period? (including CTC event dysphagia >= grade 3)
Descrição

GavageAdministeredInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C73430
UMLS 2011AA ObjectClass
C0041281
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Was a feeding tube discontinued during this reporting period?
Descrição

GavageDiscontinuedAdministrationInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25484
UMLS 2011AA Property
C1444662
NCI Thesaurus ObjectClass
C73430
UMLS 2011AA ObjectClass
C0041281
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
Date Feeding Tube Discontinued (If yes,)
Descrição

GavageEndDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C73430
UMLS 2011AA ObjectClass
C0041281
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property-2
C25496
UMLS 2011AA Property-2
C2746065
Was a tracheostomy performed during this reporting period? (e.g., for breathing difficulty)
Descrição

TracheostomyPerformedInd-3

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15341
UMLS 2011AA ObjectClass
C0040590
Was use of a tracheostomy discontinued during this reporting period?
Descrição

TracheostomyDiscontinuedInd

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25484
UMLS 2011AA Property
C1444662
NCI Thesaurus ObjectClass
C15341
UMLS 2011AA ObjectClass
C0040590
Date Tracheostomy was Closed (If yes,)
Descrição

TracheostomyDiscontinuedDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus Property
C25484
UMLS 2011AA Property
C1444662
NCI Thesaurus ObjectClass
C15341
UMLS 2011AA ObjectClass
C0040590
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 )
Descrição

DietPerformanceStatusAssessmentIntakeScale

Tipo de dados

text

Alias
NCI Metathesaurus ObjectClass
CL092952
NCI Thesaurus ObjectClass
C15222
UMLS 2011AA ObjectClass
C0012155
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C25538
UMLS 2011AA ValueDomain-2
C1512806
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.)
Descrição

DietaryPerformanceStatusAssessmentLocationScale

Tipo de dados

text

Alias
NCI Metathesaurus ObjectClass
CL092952
NCI Thesaurus ObjectClass
C15222
UMLS 2011AA ObjectClass
C0012155
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C25341
UMLS 2011AA ValueDomain-2
C0450429
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.)
Descrição

SpeechPerformanceStatusAssessmentComprehensionScale

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C38025
UMLS 2011AA ObjectClass
C0037817
NCI Metathesaurus ObjectClass
CL092952
Head & Neck: Off-protocol Treatment
Descrição

Head & Neck: Off-protocol Treatment

Was any off-protocol therapy given after completion of protocol treatment?
Descrição

Off-TreatmentTherapyAdministeredInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15368
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Off-Protocol Surgery
Descrição

Off-TreatmentSurgeryProcedureInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15329
UMLS 2011AA ObjectClass-2
C0543467
NCI Thesaurus Property
C25218
UMLS 2011AA Property
C1948041
Yes specify
Descrição

Off-TreatmentSurgeryProcedureText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15329
UMLS 2011AA ObjectClass-2
C0543467
NCI Thesaurus Property
C25218
UMLS 2011AA Property
C1948041
Off-Protocol Chemotherapy
Descrição

Off-TreatmentChemotherapyAdministeredInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass-2
C25601
UMLS 2011AA ObjectClass-2
C1518544
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Yes specify
Descrição

Off-TreatmentChemotherapyAdministeredText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass-2
C25601
UMLS 2011AA ObjectClass-2
C1518544
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Off-Protocol Immunotherapy
Descrição

Off-TreatmentImmunotherapyAdministeredInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15262
UMLS 2011AA ObjectClass
C0021083
NCI Thesaurus ObjectClass-2
C25601
UMLS 2011AA ObjectClass-2
C1518544
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Yes specify
Descrição

Off-TreatmentImmunotherapyAdministeredText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15262
UMLS 2011AA ObjectClass
C0021083
NCI Thesaurus ObjectClass-2
C25601
UMLS 2011AA ObjectClass-2
C1518544
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Off-Protocol Radiation Therapy
Descrição

Off-TreatmentRadiationTherapyAdministeredInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus ObjectClass-2
C25601
UMLS 2011AA ObjectClass-2
C1518544
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Yes specify
Descrição

Off-TreatmentRTAdministeredText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus ObjectClass-2
C25601
UMLS 2011AA ObjectClass-2
C1518544
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Off-Protocol Complementary and Alternative Medications (CAM)
Descrição

Off-TreatmentCAMAdministeredInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15178
UMLS 2011AA ObjectClass-2
C0002346
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Yes specify
Descrição

Off-TreatmentCAMAdministeredText

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15178
UMLS 2011AA ObjectClass-2
C0002346
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Other Off-Protocol Therapy
Descrição

Off-TreatmentTherapyOtherAdministeredInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15368
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Name of Other Off-Protocol Therapy (If yes,)
Descrição

Off-TreatmentTherapyOtherAdministeredText

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus ObjectClass-2
C15368
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021

Similar models

No Instruction available.

  1. StudyEvent: Head and Neck Cancers - Follow Up Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Crf Header
Protocol ID Coordinating Group
Item
Coordinating Group Protocol No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1711341 (UMLS CUI-2)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Coordinating Group Code
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C1711341 (UMLS CUI-1)
C17005 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25462 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Protocol Title
Item
Protocol Title
text
C25191 (NCI Thesaurus ValueDomain)
C2986303 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C42774 (NCI Thesaurus Property)
Patient Study ID
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Trial subject ID Participating Group
Item
Other Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
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-2)
C1257890 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Item Group
Head & Neck: Vital Status
Item
Patient's Vital Status
text
C16960 (NCI Thesaurus ObjectClass)
C3846084 (UMLS CUI-1)
C18003 (NCI Thesaurus ValueDomain)
C25688 (NCI Thesaurus ValueDomain-2)
C25717 (NCI Thesaurus Property)
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item
Primary Cause of Death
text
C25638 (NCI Thesaurus ValueDomain)
C0007465 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C28554 (NCI Thesaurus Property)
C25251 (NCI Thesaurus ValueDomain-2)
Code List
Primary Cause of Death
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To Other Cause (Due to other cause)
CL Item
Due To Second Primary Or Other Malignancy (Due to second primary or other malignancy)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Cause of Death, specify
Item
Describe cause of death
text
C25685 (NCI Thesaurus ValueDomain)
C0007465 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1521902 (UMLS CUI-2)
C28554 (NCI Thesaurus Property)
Date last contact
Item
Date of Last Contact or Death (mm dd yyyy)
date
C16960 (NCI Thesaurus ObjectClass)
C0805839 (UMLS CUI-1)
C25461 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Item
Is the patient off study (and further follow-up evaluations will not be completed)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C0008972 (UMLS 2011AA ObjectClass-2)
Code List
Is the patient off study (and further follow-up evaluations will not be completed)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Off Study Reason (If yes,)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C0008972 (UMLS 2011AA ObjectClass-2)
Code List
Off Study Reason (If yes,)
CL Item
Protocol-defined Follow-up Completed (Protocol-defined follow-up completed)
CL Item
Patient Refused Follow-up (Patient refused follow-up)
CL Item
Lost To Follow-up (Patient lost to follow-up)
CL310949 (NCI Metathesaurus)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Off-TreatmentStudyFollow-UpSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15206 (NCI Thesaurus ObjectClass-2)
C0008972 (UMLS 2011AA ObjectClass-2)
Item Group
Head & Neck: Disease Follow-up Status
Item
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form?)
text
C38148 (NCI Thesaurus ValueDomain)
C1522577 (UMLS CUI-1)
C16033 (NCI Thesaurus Property)
C0006826 (UMLS CUI-2)
C9305 (NCI Thesaurus ObjectClass)
C25365 (NCI Thesaurus Property-2)
Code List
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form?)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Follow-Up Date
Item
Date of Last Clinical Assessment (mm dd yyyy)
date
C9305 (NCI Thesaurus ObjectClass)
C3694716 (UMLS CUI-1)
C16033 (NCI Thesaurus Property)
C25365 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Item Group
Head & Neck: Notice Of Progression
DiseaseProgressionInd-3
Item
Has the patient developed a first progression (or relapse) that has not been previously reported?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25331 (NCI Thesaurus Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
Neoplasm Recurrence, locoregional
Item
Has the patient been diagnosed with first local-regional recurrence (or progression?)
boolean
C19987 (NCI Thesaurus ObjectClass)
C0027643 (UMLS CUI-1)
C25388 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C15220 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
Item
Site of First Local-Regional Progression (s mark all that apply)
text
C25331 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus ObjectClass-2)
C1279901 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25388 (NCI Thesaurus Property-2)
C1947913 (UMLS 2011AA Property-2)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
Code List
Site of First Local-Regional Progression (s mark all that apply)
CL Item
Primary (Primary Site)
C25251 (NCI Thesaurus)
C0205225 (UMLS 2011AA)
CL Item
Lymph Nodes (Lymph nodes)
CL Item
Other Specify (Other)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
FirstProgressionLocal-RegionalSiteSpecify
Item
Other specify
text
C25331 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus ObjectClass-2)
C1279901 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25388 (NCI Thesaurus Property-2)
C1947913 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Local-RegionalProgressionFirstDate
Item
Date of First Local-Regional Progression (per protocol definition leave blank if distant relapse previously reported)
date
C25331 (NCI Thesaurus ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25509 (NCI Thesaurus ValueDomain-2)
C1279901 (UMLS 2011AA ValueDomain-2)
FirstProgressionDistantPresentInd-3
Item
Has the patient been diagnosed with first distant recurrence/progression?
boolean
C19987 (NCI Thesaurus ObjectClass)
C0242656 (UMLS 2011AA ObjectClass)
C25321 (NCI Thesaurus Property)
C0443203 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Item
Site of First Distant Progression (s mark all that apply)
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25331 (NCI Thesaurus ObjectClass)
C25321 (NCI Thesaurus ObjectClass-2)
C0443203 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
Code List
Site of First Distant Progression (s mark all that apply)
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Lymph Nodes (Lymph nodes)
CL Item
Other Specify (Other)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
FirstProgressionDistantSiteSpecify
Item
Other specify
text
C25331 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus ObjectClass-2)
C1279901 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25321 (NCI Thesaurus Property-2)
C0443203 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Date of Neoplasm distal recurrence
Item
Date of First Distant Progression (leave blank if distant relapse previously reported)
date
C25164 (NCI Thesaurus ValueDomain)
C0027627 (UMLS CUI-1)
C25331 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus ValueDomain-2)
C0011008 (UMLS CUI-2)
C25275 (NCI Thesaurus Property)
Item Group
Head & Neck: Notice Of New Primary
NewCancerDiagnosisInd-3
Item
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25586 (NCI Thesaurus ObjectClass)
C0205314 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
HeadandNeckTumorSecondOccurrenceInd-2
Item
Is this a Second primary in the Upper Aero-digestive Tract? (If yes,)
boolean
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25666 (NCI Thesaurus Property)
C0205436 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
NewCancerSiteText
Item
Site of New Primary (If new primary site is AML/MDS, please submit NCI AML/MDS form.)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25586 (NCI Thesaurus ObjectClass)
C0205314 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
NewCancerDiagnosisDate
Item
Date of Diagnosis (If new primary site is AML/MDS, please submit NCI AML/MDS form.)
date
C25586 (NCI Thesaurus ObjectClass)
C0205314 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Item Group
Head & Neck: New Adverse Events
Item
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >=3), long term toxicity that has not been previously reported
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C19778 (NCI Thesaurus ObjectClass)
C1514695 (UMLS 2011AA ObjectClass)
C41331 (NCI Thesaurus ObjectClass-2)
C0877248 (UMLS 2011AA ObjectClass-2)
C25375 (NCI Thesaurus Property)
C0684224 (UMLS 2011AA Property)
Code List
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >=3), long term toxicity that has not been previously reported
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CommonToxicityCriteriaAdverseEventTermType
Item
CTC Adverse Event Term
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C45559 (NCI Thesaurus Property)
C1705313 (UMLS 2011AA Property)
CommonToxicityCriteriaAdverseEventGrade
Item
CTC Adverse Event Grade
float
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Head & Neck: Long-term Functional Assessment
Item
Does the patient currently have swallowing problems?
text
C25518 (NCI Thesaurus ObjectClass)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass-2)
C0011167 (UMLS 2011AA ObjectClass-2)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property-2)
C0011155 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Code List
Does the patient currently have swallowing problems?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
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-2)
C0011167 (UMLS 2011AA ObjectClass-2)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property-2)
C0011155 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
Code List
How long have swallowing problems been present? (If yes,)
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)
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-2)
C1533734 (UMLS 2011AA Property-2)
Code List
Does the patient currently require tube feeding?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
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-2)
C1533734 (UMLS 2011AA Property-2)
Code List
Is patient dependent on tube feeding for >50% of nutritional support? (If yes,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Was a feeding tube inserted during this reporting period? (including CTC event dysphagia >= grade 3)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Code List
Was a feeding tube inserted during this reporting period? (including CTC event dysphagia >= grade 3)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Was a feeding tube discontinued during this reporting period?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
Code List
Was a feeding tube discontinued during this reporting period?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
GavageEndDate
Item
Date Feeding Tube Discontinued (If yes,)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property-2)
C2746065 (UMLS 2011AA Property-2)
Item
Was a tracheostomy performed during this reporting period? (e.g., for breathing difficulty)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15341 (NCI Thesaurus ObjectClass)
C0040590 (UMLS 2011AA ObjectClass)
Code List
Was a tracheostomy performed during this reporting period? (e.g., for breathing difficulty)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Was use of a tracheostomy discontinued during this reporting period?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
C15341 (NCI Thesaurus ObjectClass)
C0040590 (UMLS 2011AA ObjectClass)
Code List
Was use of a tracheostomy discontinued during this reporting period?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
TracheostomyDiscontinuedDate
Item
Date Tracheostomy was Closed (If yes,)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
C15341 (NCI Thesaurus ObjectClass)
C0040590 (UMLS 2011AA ObjectClass)
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-2)
C1512806 (UMLS 2011AA ValueDomain-2)
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-2)
C0450429 (UMLS 2011AA ValueDomain-2)
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)
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)
Item Group
Head & Neck: Off-protocol Treatment
Off-TreatmentTherapyAdministeredInd-3
Item
Was any off-protocol therapy given after completion of protocol treatment?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentSurgeryProcedureInd-3
Item
Off-Protocol Surgery
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15329 (NCI Thesaurus ObjectClass-2)
C0543467 (UMLS 2011AA ObjectClass-2)
C25218 (NCI Thesaurus Property)
C1948041 (UMLS 2011AA Property)
Off-TreatmentSurgeryProcedureText
Item
Yes specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15329 (NCI Thesaurus ObjectClass-2)
C0543467 (UMLS 2011AA ObjectClass-2)
C25218 (NCI Thesaurus Property)
C1948041 (UMLS 2011AA Property)
Off-TreatmentChemotherapyAdministeredInd-3
Item
Off-Protocol Chemotherapy
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25601 (NCI Thesaurus ObjectClass-2)
C1518544 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentChemotherapyAdministeredText
Item
Yes specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25601 (NCI Thesaurus ObjectClass-2)
C1518544 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentImmunotherapyAdministeredInd-3
Item
Off-Protocol Immunotherapy
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15262 (NCI Thesaurus ObjectClass)
C0021083 (UMLS 2011AA ObjectClass)
C25601 (NCI Thesaurus ObjectClass-2)
C1518544 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentImmunotherapyAdministeredText
Item
Yes specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15262 (NCI Thesaurus ObjectClass)
C0021083 (UMLS 2011AA ObjectClass)
C25601 (NCI Thesaurus ObjectClass-2)
C1518544 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentRadiationTherapyAdministeredInd-3
Item
Off-Protocol Radiation Therapy
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25601 (NCI Thesaurus ObjectClass-2)
C1518544 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentRTAdministeredText
Item
Yes specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25601 (NCI Thesaurus ObjectClass-2)
C1518544 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentCAMAdministeredInd-3
Item
Off-Protocol Complementary and Alternative Medications (CAM)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15178 (NCI Thesaurus ObjectClass-2)
C0002346 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentCAMAdministeredText
Item
Yes specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15178 (NCI Thesaurus ObjectClass-2)
C0002346 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Off-TreatmentTherapyOtherAdministeredInd-3
Item
Other Off-Protocol Therapy
boolean
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Off-TreatmentTherapyOtherAdministeredText
Item
Name of Other Off-Protocol Therapy (If yes,)
text
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)

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