ID

8018

Beschrijving

CALGB 90203: The Expanded Prostate Cancer Index Composite (EPIC) Survey Instrument - Short Form [Form C-1145 v1 10/23/2006] Surgery With or Without Docetaxel and Leuprolide or Goserelin in Treating Patients With High-Risk Localized Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1F9FC2EA-E06D-5BE7-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1F9FC2EA-E06D-5BE7-E044-0003BA3F9857

Trefwoorden

Versies (2)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

9 januari 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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NCT00430183 Quality of Life - CALGB 90203: The Expanded Prostate Cancer Index Composite Survey Instrument - 2527357v1.0

Engels

Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice...

1 Formulieren  
Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
Beschrijving

Ccrr Module For Calgb 90202: Prostate Specific Antigen Form

CALGB Form (C-714)
Beschrijving

Form ID CALGB

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3262252
NCI Thesaurus ObjectClass
C19464
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass-2
C25442
CALGB Study No.
Beschrijving

Protocol ID CALGB

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25442
CALGB Patient ID
Beschrijving

Trial subject ID CALGB

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25442
Assessment Date (mm dd yyyy)
Beschrijving

PatientAssessmentDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Are data amended
Beschrijving

Data amended

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Patient Initials (Last, First Middle)
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Hospital No.
Beschrijving

Medical Record Number

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301894
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25261
NCI Thesaurus Property-2
C25198
Institution/Affiliate
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
Participating Group
Beschrijving

Participating Group

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2347449
NCI Thesaurus ObjectClass
C25608
NCI Thesaurus ObjectClass-2
C17005
NCI Thesaurus Property
C25364
Participating Group Study No.
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
Participating Group Patient ID
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
Interviewer Module
Beschrijving

Interviewer Module

Person Completing Form (Recommended Term for CRF Text "Responsible Person Name" Long Name of Recommended CDE, but not Doc Text Interviewer or CRA)
Beschrijving

Person Completing Form

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Assessment No.
Beschrijving

AssessmentIdentifierCount

Datatype

float

Alias
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Quality Of Life Module
Beschrijving

Quality Of Life Module

Over the past 4 weeks how often have you leaked urine
Beschrijving

ProstateQualityofLifeUrinaryLeakageSymptomScale

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25711
UMLS 2011AA Property
C1524119
NCI Thesaurus Property-2
C4876
UMLS 2011AA Property-2
C1457887
NCI Thesaurus Property-3
C40416
UMLS 2011AA Property-3
C0015376
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Which of the following best describes your urinary control during the last 4 weeks
Beschrijving

ProstateQualityofLifeUrinaryControlSymptomScale

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25711
UMLS 2011AA Property
C1524119
NCI Thesaurus Property-2
C4876
UMLS 2011AA Property-2
C1457887
NCI Thesaurus Property-3
C61299
UMLS 2011AA Property-3
C2587213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
Beschrijving

ProstateQualityofLifeAdultUndergarmentUseScale

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C17600
UMLS 2011AA Property
C0001675
NCI Thesaurus Property-2
C25340
UMLS 2011AA Property-2
C0457083
NCI Metathesaurus Property
C0453880
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Select one answer in each line.)
Beschrijving

ProstateQualityofLifeUrineLeakageProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C13283
UMLS 2011AA Property
C0042036
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C40416
UMLS 2011AA Property-3
C0015376
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Pain or burning on urination
Beschrijving

ProstateQualityofLifeUrinePainProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C13283
UMLS 2011AA Property-2
C0042036
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Bleeding with urination
Beschrijving

ProstateQualityofLifeHematuriaProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3090
UMLS 2011AA Property
C0018965
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Weak urine stream or incomplete emptying
Beschrijving

ProstateQualityofLifeIncompleteUrinationProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C25744
UMLS 2011AA Property-3
C0042034
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Need to urinate frequently during the day
Beschrijving

ProstateQualityofLifeUrinaryFrequencyProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C26906
UMLS 2011AA Property
C0677481
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Select one.)
Beschrijving

ProstateQualityofLifeOverallUrinaryProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property-2
C25711
UMLS 2011AA Property-2
C1524119
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Select one answer in each line.)
Beschrijving

ProstateQualityofLifeDefecationUrgencyProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property-2
C62788
UMLS 2011AA Property-2
C0426636
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Increased frequency of bowel movements
Beschrijving

ProstateQualityofLifeDefecationFrequencyProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property-2
C25515
UMLS 2011AA Property-2
C0439603
NCI Thesaurus Property-3
C62787
UMLS 2011AA Property-3
C0011135
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Losing control of your stools
Beschrijving

ProstateQualityofLifeAnalIncontinenceProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C43362
UMLS 2011AA Property
C0003461
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Metathesaurus Property
C0021167
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Bloody stools
Beschrijving

ProstateQualityofLifeBloodFecesProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C12434
UMLS 2011AA Property
C0229664
NCI Thesaurus Property-2
C13234
UMLS 2011AA Property-2
C0015733
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Abdominal/pelvic/rectal pain
Beschrijving

ProstateQualityofLifeAbdominalPainProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C25342
UMLS 2011AA Property-2
C0000726
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Select one.)
Beschrijving

ProstateQualityofLifeOverallBowelProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property-2
C12736
UMLS 2011AA Property-2
C0021853
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Your ability to have an erection (How would you rate each of the following during the last 4 weeks? Select one answer in each line.)
Beschrijving

ProstateQualityofLifeErectionFunctionScale

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property-2
C25740
UMLS 2011AA Property-2
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your ability to reach orgasm (climax)
Beschrijving

ProstateQualityofLifeEjaculationFunctionScale

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property-2
C16531
UMLS 2011AA Property-2
C0013746
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How would you describe the usual QUALITY of your erections during the last 4 weeks
Beschrijving

ProstateQualityofLifeErectionQualityScale

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25283
UMLS 2011AA Property
C0332306
NCI Thesaurus Property-2
C25740
UMLS 2011AA Property-2
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How would you describe the FREQUENCY of your erections during the last 4 weeks
Beschrijving

ProstateQualityofLifeErectionFrequencyScale

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property-2
C25740
UMLS 2011AA Property-2
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Overall, how would you rate your ability to function sexually during the last 4 weeks
Beschrijving

ProstateQualityofLifeOverallLibidoFunctionScale

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property-2
C25518
UMLS 2011AA Property-2
C0542341
NCI Thesaurus Property-3
C37986
UMLS 2011AA Property-3
C0023618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
Beschrijving

ProstateQualityofLifeOverallLibidoProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C37986
UMLS 2011AA Property-3
C0023618
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Select one answer in each line.)
Beschrijving

ProstateQualityofLifeHotFlashesProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3109
UMLS 2011AA Property
C0600142
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Breast tenderness/enlargement
Beschrijving

ProstateQualityofLifeBreastSwellingProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C3399
UMLS 2011AA Property-3
C0038999
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Feeling depressed
Beschrijving

ProstateQualityofLifeDepressionProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C2982
UMLS 2011AA Property
C0011570
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Lack of energy
Beschrijving

ProstateQualityofLifeFatigueProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3036
UMLS 2011AA Property
C0015672
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Change in body weight
Beschrijving

ProstateQualityofLifeWeightProblemType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25208
UMLS 2011AA Property
C0043100
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
Beschrijving

Ccrr Module For Calgb 90202: Prostate Specific Antigen Form

Completed by (Last name, First Name)
Beschrijving

Responsible Person Signature

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C25657
NCI Thesaurus Property
C25678
Date Form Completed (mm dd yyyy)
Beschrijving

Date Form Completed

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
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Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice...

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
Form ID CALGB
Item
CALGB Form (C-714)
text
C25337 (NCI Thesaurus ValueDomain)
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus ObjectClass-2)
Protocol ID CALGB
Item
CALGB Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Trial subject ID CALGB
Item
CALGB Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
PatientAssessmentDate
Item
Assessment Date (mm dd yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
Data amended
Item
Are data amended
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Medical Record Number
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (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)
Participating Group
Item
Participating Group
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 Group 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 Group 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)
Item Group
Interviewer Module
Person Completing Form
Item
Person Completing Form (Recommended Term for CRF Text "Responsible Person Name" Long Name of Recommended CDE, but not Doc Text Interviewer or CRA)
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
AssessmentIdentifierCount
Item
Assessment No.
float
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item Group
Quality Of Life Module
Item
Over the past 4 weeks how often have you leaked urine
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25711 (NCI Thesaurus Property)
C1524119 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property-2)
C1457887 (UMLS 2011AA Property-2)
C40416 (NCI Thesaurus Property-3)
C0015376 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.2
Code List
Over the past 4 weeks how often have you leaked urine
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
Item
Which of the following best describes your urinary control during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25711 (NCI Thesaurus Property)
C1524119 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property-2)
C1457887 (UMLS 2011AA Property-2)
C61299 (NCI Thesaurus Property-3)
C2587213 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.3
Code List
Which of the following best describes your urinary control during the last 4 weeks
CL Item
No Urinary Control (No urinary control whatsoever)
CL Item
Frequent Dribbling (Frequent dribbling)
CL Item
Occasional Dribbling (Occasional dribbling)
CL Item
Normal Urinary Control (Total control)
Item
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C17600 (NCI Thesaurus Property)
C0001675 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
C0453880 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.4
Code List
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
CL Item
None (No pads)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 Per Day (1 pad per day)
CL Item
2 Per Day (2 pads per day)
CL Item
3+ Per Day (3 or more pads per day)
Item
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Select one answer in each line.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C13283 (NCI Thesaurus Property)
C0042036 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C40416 (NCI Thesaurus Property-3)
C0015376 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.5
Code List
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Select one answer in each line.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Pain or burning on urination
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C13283 (NCI Thesaurus Property-2)
C0042036 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
Pain or burning on urination
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Bleeding with urination
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3090 (NCI Thesaurus Property)
C0018965 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.7
Code List
Bleeding with urination
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Weak urine stream or incomplete emptying
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25744 (NCI Thesaurus Property-3)
C0042034 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.8
Code List
Weak urine stream or incomplete emptying
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Need to urinate frequently during the day
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C26906 (NCI Thesaurus Property)
C0677481 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.9
Code List
Need to urinate frequently during the day
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Select one.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25711 (NCI Thesaurus Property-2)
C1524119 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.10
Code List
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Select one.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Select one answer in each line.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C62788 (NCI Thesaurus Property-2)
C0426636 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.11
Code List
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Select one answer in each line.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Increased frequency of bowel movements
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25515 (NCI Thesaurus Property-2)
C0439603 (UMLS 2011AA Property-2)
C62787 (NCI Thesaurus Property-3)
C0011135 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.12
Code List
Increased frequency of bowel movements
CL Item
Severe Problem (Big problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
Item
Losing control of your stools
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C43362 (NCI Thesaurus Property)
C0003461 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C0021167 (NCI Metathesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.13
Code List
Losing control of your stools
CL Item
Severe Problem (Big problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
Item
Bloody stools
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C12434 (NCI Thesaurus Property)
C0229664 (UMLS 2011AA Property)
C13234 (NCI Thesaurus Property-2)
C0015733 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.14
Code List
Bloody stools
CL Item
Severe Problem (Big problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
Item
Abdominal/pelvic/rectal pain
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25342 (NCI Thesaurus Property-2)
C0000726 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.15
Code List
Abdominal/pelvic/rectal pain
CL Item
Severe Problem (Big problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
Item
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Select one.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C12736 (NCI Thesaurus Property-2)
C0021853 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.16
Code List
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Select one.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Your ability to have an erection (How would you rate each of the following during the last 4 weeks? Select one answer in each line.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property-2)
C0030847 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.17
Code List
Your ability to have an erection (How would you rate each of the following during the last 4 weeks? Select one answer in each line.)
CL Item
None (Very poor to None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
Your ability to reach orgasm (climax)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C16531 (NCI Thesaurus Property-2)
C0013746 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.18
Code List
Your ability to reach orgasm (climax)
CL Item
None (Very poor to None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
How would you describe the usual QUALITY of your erections during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25283 (NCI Thesaurus Property)
C0332306 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property-2)
C0030847 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.19
Code List
How would you describe the usual QUALITY of your erections during the last 4 weeks
CL Item
None (None at all)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Not Firm Enough For Any Sexual Activity (Not firm enough for any sexual activity)
CL Item
Firm Enough For Masturbation And Foreplay Only (Firm enough for masturbation and foreplay only)
CL Item
Firm Enough For Intercourse (Firm enough for intercourse)
Item
How would you describe the FREQUENCY of your erections during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property-2)
C0030847 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.20
Code List
How would you describe the FREQUENCY of your erections during the last 4 weeks
CL Item
Never (I NEVER had an erection when I wanted one)
CL Item
Less Than Half (I had an erection LESS THAN HALF the time I wanted one)
CL Item
About Half (approximately 50%) (I had an erection ABOUT HALF the time I wanted one)
CL Item
More Than Half (I had an erection MORE THAN HALF the time I wanted one)
CL Item
Normal (I had an erection WHENEVER I wanted one)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
Item
Overall, how would you rate your ability to function sexually during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25518 (NCI Thesaurus Property-2)
C0542341 (UMLS 2011AA Property-2)
C37986 (NCI Thesaurus Property-3)
C0023618 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.21
Code List
Overall, how would you rate your ability to function sexually during the last 4 weeks
CL Item
Very Poor (Very poor)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C37986 (NCI Thesaurus Property-3)
C0023618 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.22
Code List
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Select one answer in each line.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3109 (NCI Thesaurus Property)
C0600142 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.23
Code List
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Select one answer in each line.)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Breast tenderness/enlargement
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C3399 (NCI Thesaurus Property-3)
C0038999 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.24
Code List
Breast tenderness/enlargement
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Feeling depressed
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C2982 (NCI Thesaurus Property)
C0011570 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.25
Code List
Feeling depressed
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Lack of energy
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3036 (NCI Thesaurus Property)
C0015672 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.26
Code List
Lack of energy
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Change in body weight
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25208 (NCI Thesaurus Property)
C0043100 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.27
Code List
Change in body weight
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item Group
Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
Responsible Person Signature
Item
Completed by (Last name, First Name)
text
C25704 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C25678 (NCI Thesaurus Property)
Date Form Completed
Item
Date Form Completed (mm dd yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
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