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ID
8145
Descripción
RTOG-0412 A5: Demographic Data Form - version 2 Cisplatin and Docetaxel With or Without Radiation Therapy in Treating Patients Who Are Undergoing Surgery for Newly Diagnosed Stage III Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E499E60B-975C-4FA9-E034-0003BA3F9857
Link
Palabras clave
Versiones (4)
- 19/9/12 19/9/12 -
- 9/1/15 9/1/15 - Martin Dugas
- 9/1/15 9/1/15 - Martin Dugas
- 3/7/15 3/7/15 -
Subido en
9 de enero de 2015
DOI
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Licencia
Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00113386 Demographic - RTOG-0412 A5: Demographic Data Form - version 2 - 2292933v3.0
Radiation Therapy Oncology Group Phase III Lung Pre-Op Chemotherapy vs. Pre-Op Concurrent Chemoradiation for NSCLC
- StudyEvent: RTOG-0412 A5: Demographic Data Form - version 2
Similar models
Radiation Therapy Oncology Group Phase III Lung Pre-Op Chemotherapy vs. Pre-Op Concurrent Chemoradiation for NSCLC
- StudyEvent: RTOG-0412 A5: Demographic Data Form - version 2
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Protocol ID RTOG
Item
RTOG Study
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Case#
Item
Case #
text
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Institution Number
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Participant's Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
FormCompletionDate
Item
Date Completed (INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling in boxes or blanks as requested. See separate page for instructions)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Who completed this form? (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C1273518 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C1273518 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL Item
Self (Self)
C25200 (NCI Thesaurus)
C0036588 (UMLS 2011AA)
C0036588 (UMLS 2011AA)
CL Item
Staff (Staff)
CL Item
Other Person (Other person)
CL Item
Not Applicable, No Items Completed (Not applicable, no items completed)
Item
Race (Check one box only)
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White, not Hispanic origin)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
C0007457 (UMLS 2011AA)
CL Item
Hispanic (Hispanic)
CL Item
A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black, not Hispanic origin)
C16352 (NCI Thesaurus)
C0085756 (UMLS 2011AA)
C0085756 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands (Native Hawaiian or other Pacific Islander)
CL Item
A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
C0078988 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment (Native American / Alaskan Nation)
CL Item
Other (Other)
CL Item
Patient Is Unsure Of Their Race (Unknown / I prefer not to answer)
Item
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C29933 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C29933 (NCI Thesaurus Property)
Code List
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
CL Item
White, not Hispanic origin (White, not Hispanic origin)
CL Item
Hispanic (Hispanic)
CL Item
Black, not Hispanic origin (Black, not Hispanic origin)
CL Item
Native Hawaiian or other Pacific Islander (Native Hawaiian or other Pacific Islander)
CL Item
Asian (Asian)
CL Item
Native American / Alaskan Nation (Native American / Alaskan Nation)
CL Item
Patient Is Unsure Of Their Ethnicity (Unknown / I prefer not to answer)
CL Item
A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race (HISPANIC OR LATINO)
CL Item
Patient Refused Or Data Not Available (Not reported)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (NOT HISPANIC OR LATINO)
C41222 (NCI Thesaurus)
C1518424 (UMLS 2011AA)
C1518424 (UMLS 2011AA)
Item
Highest school grade completed (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property-2)
C1522410 (UMLS 2011AA Property-2)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property-2)
C1522410 (UMLS 2011AA Property-2)
CL Item
8th Or Less (8th or less)
CL Item
9 - 11th Grade (9 - 11th Grade)
CL Item
High School Graduate / Ged (High school graduate / GED)
CL Item
Vocational / Technical School (Vocational / technical school)
CL Item
Associate Degree / Some College (Associate degree / some college)
CL Item
Bachelor's Degree (Bachelor's degree)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
C1511035 (UMLS 2011AA)
CL Item
Advanced Degree (Advanced degree)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
PersonHighestEducationSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property-2)
C1522410 (UMLS 2011AA Property-2)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property-2)
C1522410 (UMLS 2011AA Property-2)
Item
Religion during childhood (Check one box)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C17085 (NCI Thesaurus Property-2)
C0035039 (UMLS 2011AA Property-2)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C17085 (NCI Thesaurus Property-2)
C0035039 (UMLS 2011AA Property-2)
CL Item
Protestant (Protestant)
CL Item
Catholic (Catholic)
CL Item
Jewish (Jewish)
C0178443 (NCI Metathesaurus)
CL Item
Morman/latter Day Saints (Mormon/Latter Day Saints)
CL Item
Muslim / Islam (Muslim / Islam)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
CL Item
Other, Specify (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
PersonPediatricReligionSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C17085 (NCI Thesaurus Property-2)
C0035039 (UMLS 2011AA Property-2)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C17085 (NCI Thesaurus Property-2)
C0035039 (UMLS 2011AA Property-2)
Item
Marital status (Check one box)
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
C0206275 (UMLS 2011AA)
CL Item
Single (Single)
CL Item
Divorced (Divorced/Separated)
C0086170 (NCI Metathesaurus)
CL Item
Living As Married (Living as married)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Item
Where were you born? (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25464 (NCI Thesaurus Property)
C0454664 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25464 (NCI Thesaurus Property)
C0454664 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
CL Item
Usa (USA)
CL Item
Other Country (Other country)
PatientBirthStateSpecify
Item
USA, specify the 2 letter State code (e.g. NY)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C30010 (NCI Thesaurus Property)
C1301808 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C30010 (NCI Thesaurus Property)
C1301808 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
PatientBirthCountrySpecify
Item
Other country, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25464 (NCI Thesaurus Property)
C0454664 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25464 (NCI Thesaurus Property)
C0454664 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
Item
Where did you live the longest (Check one box)
text
C0030705 (NCI Metathesaurus ObjectClass)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C25330 (NCI Thesaurus Property-2)
C0449238 (UMLS 2011AA Property-2)
C25273 (NCI Thesaurus Property-3)
C0237096 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C25330 (NCI Thesaurus Property-2)
C0449238 (UMLS 2011AA Property-2)
C25273 (NCI Thesaurus Property-3)
C0237096 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL Item
Usa (USA)
CL Item
Other Country (Other country)
PatientStateLongestDurationResidenceCode
Item
USA, specify the 2 letter State code (e.g. NY)
text
C0030705 (NCI Metathesaurus ObjectClass)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C30010 (NCI Thesaurus Property-2)
C1301808 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus Property-3)
C0449238 (UMLS 2011AA Property-3)
C25273 (NCI Thesaurus Property-4)
C0237096 (UMLS 2011AA Property-4)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C30010 (NCI Thesaurus ValueDomain-2)
C1301808 (UMLS 2011AA ValueDomain-2)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C30010 (NCI Thesaurus Property-2)
C1301808 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus Property-3)
C0449238 (UMLS 2011AA Property-3)
C25273 (NCI Thesaurus Property-4)
C0237096 (UMLS 2011AA Property-4)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C30010 (NCI Thesaurus ValueDomain-2)
C1301808 (UMLS 2011AA ValueDomain-2)
PatientCountryLongestDurationResidenceName
Item
Other country, specify (Cigarette History?)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C25464 (NCI Thesaurus Property-2)
C0454664 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus Property-3)
C0449238 (UMLS 2011AA Property-3)
C25273 (NCI Thesaurus Property-4)
C0237096 (UMLS 2011AA Property-4)
C25464 (NCI Thesaurus ValueDomain)
C0454664 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C0027365 (UMLS 2011AA ValueDomain-2)
C0030705 (UMLS 2011AA ObjectClass)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C25464 (NCI Thesaurus Property-2)
C0454664 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus Property-3)
C0449238 (UMLS 2011AA Property-3)
C25273 (NCI Thesaurus Property-4)
C0237096 (UMLS 2011AA Property-4)
C25464 (NCI Thesaurus ValueDomain)
C0454664 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C0027365 (UMLS 2011AA ValueDomain-2)
Item
Smoked at least 100 cigarette (5 packs) during lifetime
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C1522602 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Yes, Currently Smoke (Yes, currently smoke)
AgeBeganSmokinginYears
Item
Age began smoking cigarettes
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property-2)
C0700219 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C29848 (NCI Thesaurus ValueDomain-2)
C0439234 (UMLS 2011AA ValueDomain-2)
C25150 (NCI Thesaurus ValueDomain-3)
C0001779 (UMLS 2011AA ValueDomain-3)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property-2)
C0700219 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C29848 (NCI Thesaurus ValueDomain-2)
C0439234 (UMLS 2011AA ValueDomain-2)
C25150 (NCI Thesaurus ValueDomain-3)
C0001779 (UMLS 2011AA ValueDomain-3)
Numberofyearssmokedcigarettes
Item
Number of years smoked cigarettes
text
Averagenumberofcigarettessmokedperday
Item
Average number of cigarettes smoked per day
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientSmokingCessationAgeYear
Item
If quit, age stopped smoking completely
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C0085134 (NCI Metathesaurus Property)
C0030705 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C0085134 (NCI Metathesaurus Property)
Item
If you have had any of the illnesses listed below, please check yes for those that apply (= Yes 2)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
Code List
If you have had any of the illnesses listed below, please check yes for those that apply (= Yes 2)
CL Item
Heart Problems (Heart problems)
CL Item
Lung Problems (Lung problems)
CL Item
High Blood Pressure (High blood pressure)
CL Item
Bleeding Problems (Bleeding problems)
CL Item
Circulation Problems (Circulation problems)
CL Item
Liver Problems (Liver problems)
CL Item
Diabetes Or Sugar In Urine (Diabetes or sugar in urine)
CL Item
Kidney/urine Problems (Kidney/urine problems)
CL Item
Stroke (Stroke)
CL Item
Thyroid Problems (Thyroid problems)
CL Item
Seizure (Seizure)
C2962 (NCI Thesaurus)
C0036572 (UMLS 2011AA)
C0036572 (UMLS 2011AA)
CL Item
Hiv/aids (HIV/AIDS)
CL Item
Frequent Infections (Frequent infections)
CL Item
Psychological Problems (Psychological problems)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
OtherDiseaseDiagnosisSpecify
Item
Specify other
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
Item
How many of the following family members (living and dead) do you have (Include only those who are blood-related.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25173 (NCI Thesaurus ObjectClass)
C0015576 (UMLS 2011AA ObjectClass)
C21480 (NCI Thesaurus Property)
C0080103 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C25173 (NCI Thesaurus ObjectClass)
C0015576 (UMLS 2011AA ObjectClass)
C21480 (NCI Thesaurus Property)
C0080103 (UMLS 2011AA Property)
Code List
How many of the following family members (living and dead) do you have (Include only those who are blood-related.)
CL Item
Brothers (Brothers)
CL Item
Sisters (Sisters)
C0337514 (NCI Metathesaurus)
CL Item
Daughters (Daughters)
CL Item
Sons (Sons)
PatientAdoptedInd-3
Item
Are you adopted (Check one)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25290 (NCI Thesaurus Property)
C0425382 (UMLS 2011AA Property)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25290 (NCI Thesaurus Property)
C0425382 (UMLS 2011AA Property)
Item
Blood relative with cancer (= yes 2)
text
C25173 (NCI Thesaurus ObjectClass)
C0015576 (UMLS 2011AA ObjectClass)
C21480 (NCI Thesaurus ObjectClass-2)
C0080103 (UMLS 2011AA ObjectClass-2)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C0015576 (UMLS 2011AA ObjectClass)
C21480 (NCI Thesaurus ObjectClass-2)
C0080103 (UMLS 2011AA ObjectClass-2)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL Item
Father (Father)
C25174 (NCI Thesaurus)
C0015671 (UMLS 2011AA)
C0015671 (UMLS 2011AA)
CL Item
Mother (Mother)
C25189 (NCI Thesaurus)
C0026591 (UMLS 2011AA)
C0026591 (UMLS 2011AA)
CL Item
Brother #1 (Brother #1)
CL Item
Brother #2 (Brother #2)
CL Item
Brother #3 (Brother #3)
CL Item
Brother #4 (Brother #4)
CL Item
Sister #1 (Sister #1)
CL Item
Sister #2 (Sister #2)
CL Item
Sister #3 (Sister #3)
CL Item
Sister #4 (Sister #4)
CL Item
Child #1 (Child #1)
CL Item
Child #2 (Child #2)
CL Item
Child #3 (Child #3)
CL Item
Child #4 (Child #4)
PersonFirstCancerDiagnosisAgeYearCount
Item
Age when first cancer diagnosed
float
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C25150 (NCI Thesaurus Property-4)
C0001779 (UMLS 2011AA Property-4)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C25150 (NCI Thesaurus Property-4)
C0001779 (UMLS 2011AA Property-4)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item
Type of cancer (= yes 2)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C0332307 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
C0024109 (UMLS 2011AA)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
C0006141 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
C0009368 (UMLS 2011AA)
CL Item
Prostate (Prostate)
C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)
C0033572 (UMLS 2011AA)
CL Item
Head & Neck (Head & Neck)
CL Item
Non Melanoma Skin (Non Melanoma Skin)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
CancerSiteSpecify
Item
specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
CancerPreventionTrialKnowledgeDocumentedInd-2
Item
Have you ever heard of Cancer Prevention Trials (Check one box)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
C0376554 (NCI Metathesaurus Property)
C1512698 (UMLS 2011AA ValueDomain)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
C0376554 (NCI Metathesaurus Property)
Item
How likely would you be to volunteer to participate in Cancer Prevention Trials (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
C0349674 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
Code List
How likely would you be to volunteer to participate in Cancer Prevention Trials (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
CL Item
1 (1)
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)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
C0205448 (UMLS 2011AA)
Other,specify
Item
Other, specify
text