ID

7433

Description

Southwest Oncology Group S0421 Symptom Questionnaires: Step 1 Randomization Form Docetaxel and Prednisone With or Without Atrasentan in Treating Patients With Stage IV Prostate Cancer and Bone Metastases That Did Not Respond to Previous Hormone Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F15B296A-D2C9-33BF-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F15B296A-D2C9-33BF-E034-0003BA3F9857

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/12/15 6/12/15 -
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Metastatic Cancer NCT00134056 Quality of Life - Southwest Oncology Group S0421 Symptom Questionnaires: Step 1 Randomization Form - 2305311v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Southwest Oncology Group S0421 Symptom Questionnaires: Step 1 Randomization Form
    1. No Instruction available.
Unnamed 1
Description

Unnamed 1

SWOG Patient ID
Description

Trial subject ID SWOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1519429
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
SWOG Study No.
Description

Protocol ID SWOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1519429
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
Registration Step
Description

Registration Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1514821
NCI Thesaurus ObjectClass
C25646
UMLS CUI-2
C0237753
NCI Thesaurus Property
C16154
NCI Thesaurus ValueDomain-2
C16154
Patient Initials (L, F M)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Date form completed
Description

Date Form Completed

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
Planned Assessment
Description

PlannedAssessmentPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Institution/Affiliate
Description

Institution Name

Data type

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
Physician
Description

Investigator Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2826892
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C17089
NCI Thesaurus ObjectClass-2
C25644
Participating Group Name
Description

Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2347449
NCI Thesaurus ObjectClass
C25608
NCI Thesaurus ObjectClass-2
C17005
NCI Thesaurus Property
C25364
Participating Study No.
Description

Study Number Participating Group

Data type

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
Participating Patient ID
Description

Trial subject ID Participating Group

Data type

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
Have you had pain than these everyday kinds of pain today? (Throughout our lives, most of us have had pain from time to time such as minor headaches, sprains, and toothaches.)
Description

PatientAtypicalPainInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C25428
UMLS 2011AA Property-2
C0205182
Please rate your pain by selecting the one number that best describes your pain at its WORST in the past 24 hours.
Description

PatientWorstPainScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C25719
UMLS 2011AA Property-2
C1522166
Please rate your pain by selecting the one number that best describes your pain at its LEAST in the past 24 hours.
Description

PatientLeastPainScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C61422
UMLS 2011AA Property-2
C0547044
Please rate your pain by selecting the one number that best describes your pain on the AVERAGE.
Description

PatientAveragePainScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C37917
UMLS 2011AA Property-2
C1510992
Please rate your pain by selecting the one number that tells how much pain you have RIGHT NOW.
Description

PatientCurrentPainScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus Property-2
C3303
UMLS 2011AA Property-2
C0030193
Are you receiving treatments or medications for your pain?
Description

PainMedicationCurrentAdministrationInd-2

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C3303
UMLS 2011AA ObjectClass
C0030193
NCI Thesaurus ObjectClass-2
C459
UMLS 2011AA ObjectClass-2
C0013227
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
In the past 24 hours, how much RELIEF have pain treatments or medications provided? (Please select the percentage that most shows how much.)
Description

MedicationPainCessationAdministrationScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C459
UMLS 2011AA ObjectClass
C0013227
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
NCI Thesaurus Property-3
C61497
UMLS 2011AA Property-3
C1880019
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your General Activity
Description

GeneralizedActivitiesofDailyLivingPainRestrictedScale

Data type

text

Alias
NCI Metathesaurus ObjectClass
C0001288
NCI Thesaurus ObjectClass
C63764
UMLS 2011AA ObjectClass
C0205246
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Metathesaurus Property
CL212559
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Mood
Description

PatientMoodPainRestrictedScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0026516
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Metathesaurus Property
CL212559
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Walking ability
Description

PatientWalkingPainRestrictedScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0080331
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Metathesaurus Property
CL212559
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Normal work (includes both work outside the home and housework)
Description

NormalWorkPainRestrictedScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C14165
UMLS 2011AA ObjectClass
C0205307
NCI Metathesaurus ObjectClass
C0043227
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Metathesaurus Property
CL212559
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Relations with other people
Description

PatientInterpersonalInteractionPainRestrictedScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0021797
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Metathesaurus Property
CL212559
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Sleep
Description

PatientSleepPainRestrictedScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0037313
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Metathesaurus Property
CL212559
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Enjoyment of life
Description

PatientEnjoymentofLifePainRestrictedScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
CL196329
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Metathesaurus Property
CL212559
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Please choose one response to describe your pain
Description

PatientPainDescriptionScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C25365
UMLS 2011AA Property-2
C0678257
How much during the past week did you feel full of pep?
Description

PatientVitalityAssessmentScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0291944
How much during the past week did you have a lot of energy?
Description

PatientEnergyAssessmentScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C48058
UMLS 2011AA Property-2
C0542479
How much during the past week did you feel worn out?
Description

PatientFatigueAssessmentScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3036
UMLS 2011AA Property-2
C0015672
How much during the past week did you feel tired?
Description

PatientLethargyAssessmentScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0023380
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1 forms
  1. StudyEvent: Southwest Oncology Group S0421 Symptom Questionnaires: Step 1 Randomization Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed 1
Trial subject ID SWOG
Item
SWOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
Protocol ID SWOG
Item
SWOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
Registration Number
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Date Form Completed
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Item
Planned Assessment
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.1
Code List
Planned Assessment
CL Item
Prestudy (Prestudy)
CL Item
Week 4 (Week 4)
CL Item
Week 7 (Week 7)
CL Item
Week 10 (Week 10)
CL Item
Week 13 (Week 13)
CL Item
Week 16 (Week 16)
CL Item
Week 19 (Week 19)
CL Item
Week 22 (Week 22)
CL Item
Week 25 (Week 25)
CL Item
Week 28 (Week 28)
CL Item
Week 31 (Week 31)
CL Item
Week 34 (Week 34)
CL Item
Week 37 (Week 37)
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)
Investigator Name
Item
Physician
text
C25191 (NCI Thesaurus ValueDomain)
C2826892 (UMLS CUI-1)
C25364 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C25644 (NCI Thesaurus ObjectClass-2)
Participating Group
Item
Participating Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Participating 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)
PatientAtypicalPainInd-2
Item
Have you had pain than these everyday kinds of pain today? (Throughout our lives, most of us have had pain from time to time such as minor headaches, sprains, and toothaches.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25428 (NCI Thesaurus Property-2)
C0205182 (UMLS 2011AA Property-2)
Item
Please rate your pain by selecting the one number that best describes your pain at its WORST in the past 24 hours.
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25719 (NCI Thesaurus Property-2)
C1522166 (UMLS 2011AA Property-2)
CL.3
Code List
Please rate your pain by selecting the one number that best describes your pain at its WORST in the past 24 hours.
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
Please rate your pain by selecting the one number that best describes your pain at its LEAST in the past 24 hours.
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C61422 (NCI Thesaurus Property-2)
C0547044 (UMLS 2011AA Property-2)
CL.4
Code List
Please rate your pain by selecting the one number that best describes your pain at its LEAST in the past 24 hours.
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
Please rate your pain by selecting the one number that best describes your pain on the AVERAGE.
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C37917 (NCI Thesaurus Property-2)
C1510992 (UMLS 2011AA Property-2)
CL.5
Code List
Please rate your pain by selecting the one number that best describes your pain on the AVERAGE.
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
Item
Please rate your pain by selecting the one number that tells how much pain you have RIGHT NOW.
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C3303 (NCI Thesaurus Property-2)
C0030193 (UMLS 2011AA Property-2)
CL.6
Code List
Please rate your pain by selecting the one number that tells how much pain you have RIGHT NOW.
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
CL Item
Whole Number (10)
PainMedicationCurrentAdministrationInd-2
Item
Are you receiving treatments or medications for your pain?
boolean
C3303 (NCI Thesaurus ObjectClass)
C0030193 (UMLS 2011AA ObjectClass)
C459 (NCI Thesaurus ObjectClass-2)
C0013227 (UMLS 2011AA ObjectClass-2)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
In the past 24 hours, how much RELIEF have pain treatments or medications provided? (Please select the percentage that most shows how much.)
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C61497 (NCI Thesaurus Property-3)
C1880019 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.8
Code List
In the past 24 hours, how much RELIEF have pain treatments or medications provided? (Please select the percentage that most shows how much.)
CL Item
0% (0)
CL Item
10% (0.1)
CL Item
20% (0.2)
CL Item
30% (0.3)
CL Item
40% (0.4)
CL Item
50% (0.5)
CL Item
60% (0.6)
CL Item
70% (0.7)
CL Item
80% (0.8)
CL Item
90% (0.9)
CL Item
100% (1)
Item
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your General Activity
text
C0001288 (NCI Metathesaurus ObjectClass)
C63764 (NCI Thesaurus ObjectClass)
C0205246 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
CL212559 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.9
Code List
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your General Activity
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Mood
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0026516 (NCI Metathesaurus ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
CL212559 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.10
Code List
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Mood
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Walking ability
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0080331 (NCI Metathesaurus ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
CL212559 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.11
Code List
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Walking ability
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Normal work (includes both work outside the home and housework)
text
C14165 (NCI Thesaurus ObjectClass)
C0205307 (UMLS 2011AA ObjectClass)
C0043227 (NCI Metathesaurus ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
CL212559 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.12
Code List
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Normal work (includes both work outside the home and housework)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Relations with other people
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0021797 (NCI Metathesaurus ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
CL212559 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.13
Code List
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Relations with other people
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Sleep
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0037313 (NCI Metathesaurus ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
CL212559 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.14
Code List
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Sleep
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Enjoyment of life
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
CL196329 (NCI Metathesaurus ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
CL212559 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.15
Code List
Select the one number that describes how, during the past 24 hours, PAIN HAS INTERFERED with your Enjoyment of life
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Please choose one response to describe your pain
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
CL.16
Code List
Please choose one response to describe your pain
CL Item
No Pain (No pain)
CL Item
Mild (Mild)
C70666 (NCI Thesaurus)
C2945599 (UMLS 2011AA)
CL Item
Discomforting (Discomforting)
CL Item
Distressing (Distressing)
CL Item
Horrible (Horrible)
CL Item
Excruciating (Excruciating)
Item
How much during the past week did you feel full of pep?
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0291944 (NCI Metathesaurus Property)
CL.17
Code List
How much during the past week did you feel full of pep?
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
How much during the past week did you have a lot of energy?
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C48058 (NCI Thesaurus Property-2)
C0542479 (UMLS 2011AA Property-2)
CL.18
Code List
How much during the past week did you have a lot of energy?
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
How much during the past week did you feel worn out?
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3036 (NCI Thesaurus Property-2)
C0015672 (UMLS 2011AA Property-2)
CL.19
Code List
How much during the past week did you feel worn out?
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
How much during the past week did you feel tired?
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0023380 (NCI Metathesaurus Property)
CL.20
Code List
How much during the past week did you feel tired?
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
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