ID

8250

Beschreibung

A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2 Radiation Therapy and Stereotactic Radiosurgery With or Without Temozolomide or Erlotinib in Treating Patients With Brain Metastases Secondary to Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D81B5AB0-2D5B-616A-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D81B5AB0-2D5B-616A-E034-0003BA12F5E7

Stichworte

Versionen (4)
  1. 19.09.12 19.09.12 -
  2. 11.08.14 11.08.14 - Martin Dugas
  3. 09.01.15 09.01.15 - Martin Dugas
  4. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

9. Januar 2015

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Lung Cancer NCT00096265 Demographic - A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2 - 2277657v3.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2
    1. No Instruction available.
Header
Beschreibung

Header

[RTOG Study No.]
Beschreibung

Protocol ID RTOG

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Case #
Beschreibung

Case#

Datentyp

text

Institution
Beschreibung

Institution Name

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Institution No.
Beschreibung

Institution Number

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Participant's Initials
Beschreibung

Patient Initials

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Participant's I.D. No.
Beschreibung

Trial subject ID RTOG

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Module 1
Beschreibung

Module 1

Date Completed
Beschreibung

Form Completion Date

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
If this is a revised or corrected form, indicate by checking box.
Beschreibung

Data amended

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Module 2
Beschreibung

Module 2

Who completed this form? (check one box)
Beschreibung

Whocompletedthisform?

Datentyp

text

Other, specify
Beschreibung

PatientRaceSpecify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
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.)
Beschreibung

PatientRaceCategory

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
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.)
Beschreibung

PatientRaceCategory

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Highest school grade completed (Check one box)
Beschreibung

Highestschoolgradecompleted

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C16529
UMLS 2011AA Property
C0013622
NCI Thesaurus Property-2
C25525
UMLS 2011AA Property-2
C1522410
Other, specify
Beschreibung

Other,specify(highestschoolgradecompleted)

Datentyp

text

Religion during childhood (check one box)
Beschreibung

PersonPediatricReligionName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C39299
UMLS 2011AA Property
C0231335
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus Property-2
C17085
UMLS 2011AA Property-2
C0035039
Other, specify
Beschreibung

ReligionduringchildhoodOther,specify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Marital status (check one box)
Beschreibung

Maritalstatus

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Where were you born? (check one box Check the box of the country where you were born.)
Beschreibung

Wherewereyouborn?

Datentyp

text

Other country, specify
Beschreibung

Othercountry,specify(whereyouwereborn)

Datentyp

text

Where did you live the longest (check one box)
Beschreibung

Wheredidyoulivethelongest

Datentyp

text

specify the 2 letter State code, eg NY
Beschreibung

USA,specifythe2letterStatecode,egNY

Datentyp

text

specify the 2 letter State code, eg NY
Beschreibung

USA,specifythe2letterStatecode,egNY

Datentyp

text

Other country, specify
Beschreibung

Wheredidyoulivethelongest,othercountry,specify

Datentyp

text

Smoked at least 100 cigarette (5 packs) during lifetime
Beschreibung

Smoking history

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1519384
NCI Thesaurus Property
C20989
NCI Thesaurus ObjectClass
C29719
Age began smoking cigarettes
Beschreibung

PatientInitialCigaretteSmokingAgeYearCount

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property-2
C18270
UMLS 2011AA Property-2
C0700219
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Number of years smoked cigarettes
Beschreibung

Numberofyearssmokedcigarettes

Datentyp

text

Average number of cigarettes smoked per day
Beschreibung

Averagenumberofcigarettessmokedperday

Datentyp

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
If quit, age stopped smoking completely
Beschreibung

PatientSmokingCessationAgeYear

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
NCI Metathesaurus Property
C0085134
If you have had any of the illness listed below, please check yes for those that apply. (check = Yes 2)
Beschreibung

Ifyouhavehadanyoftheillnesslistedbelow,pleasecheckyesforthosethatapply.

Datentyp

text

Specify other
Beschreibung

Specifyother(illness)

Datentyp

text

Family History
Beschreibung

Family History

Brothers
Beschreibung

Brothers

Datentyp

text

Sisters
Beschreibung

Sisters

Datentyp

text

Sons
Beschreibung

Sons

Datentyp

text

Daughters
Beschreibung

Daughters

Datentyp

text

Are you adopted?
Beschreibung

PatientAdoptedInd-3

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25290
UMLS 2011AA Property
C0425382
Blood relative with cancer
Beschreibung

Bloodrelativewithcancer

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Age when first cancer diagnosed
Beschreibung

PersonFirstCancerDiagnosisAgeYearCount

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C9305
UMLS 2011AA Property
C0006826
NCI Thesaurus Property-2
C25509
UMLS 2011AA Property-2
C1279901
NCI Thesaurus Property-3
C15220
UMLS 2011AA Property-3
C0011900
NCI Thesaurus Property-4
C25150
UMLS 2011AA Property-4
C0001779
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Type of Cancer
Beschreibung

TypeofCancer

Datentyp

text

Specify
Beschreibung

specify(othercancers)

Datentyp

text

Have you ever heard of Cancer Prevention Trials?
Beschreibung

CancerPreventionTrialKnowledgeDocumentedInd-2

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
NCI Thesaurus Property
C25356
UMLS 2011AA Property
C1301725
NCI Metathesaurus Property
C0376554
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.)
Beschreibung

CancerPreventionTrialParticipationScale

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
Zum Seitenanfang zurückkehren

Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header
Item
[RTOG Study No.]
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)
CL.1
Code List
[RTOG Study No.]
CL Item
RTOG Study 0320 (RTOG Study 0320)
Case#
Item
Case #
text
Institution Name
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
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)
Patient Initials
Item
Participant's Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
Participant's I.D. No.
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)
Item Group
Module 1
Form Completion Date
Item
Date Completed
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Data amended
Item
If this is a revised or corrected form, indicate by checking box.
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Module 2
Item
Who completed this form? (check one box)
text
CL.2
Code List
Who completed this form? (check one box)
CL Item
Self (Self)
C25200 (NCI Thesaurus)
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)
PatientRaceSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
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)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.4
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
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)
CL Item
Hispanic (Hispanic)
CL Item
Black, not Hispanic origin (Black, not Hispanic origin)
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)
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
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)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.4
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
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)
CL Item
Hispanic (Hispanic)
CL Item
Black, not Hispanic origin (Black, not Hispanic origin)
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)
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
Patient Is Unsure Of Their Race (Unknown/I prefer not to answer)
Item
Highest school grade completed (Check one box)
text
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.5
Code List
Highest school grade completed (Check one box)
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
Bachelor's Degree (Associate degree/some college)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
CL Item
Bachelor's Degree (Bachelor's degree)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
CL Item
Advanced Degree (Advanced degree)
CL Item
Other, Specify (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Other,specify(highestschoolgradecompleted)
Item
Other, specify
text
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)
CL.6
Code List
Religion during childhood (check one box)
CL Item
Protestant (Protestant)
CL Item
Catholic (Catholic)
CL Item
Jewish (Jewish)
C0178443 (NCI Metathesaurus)
CL Item
Morman/latter Day Saints (Morman/Latter Day Saints)
CL Item
Muslim / Islam (Muslim/Islam)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Other, Specify (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
ReligionduringchildhoodOther,specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Marital status (check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.7
Code List
Marital status (check one box)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
CL Item
Single (Single)
CL Item
Divorced/separated (Divorced/Separated)
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 Check the box of the country where you were born.)
text
CL.8
Code List
Where were you born? (check one box Check the box of the country where you were born.)
CL Item
Usa, Specify The 2 Letter State Code, Eg Ny (USA)
CL Item
Other Country, Specify (Other country)
Othercountry,specify(whereyouwereborn)
Item
Other country, specify
text
Item
Where did you live the longest (check one box)
text
CL.9
Code List
Where did you live the longest (check one box)
CL Item
Usa, Specify The 2 Letter State Code, Eg Ny (USA)
CL Item
Other Country, Specify (Other country)
USA,specifythe2letterStatecode,egNY
Item
specify the 2 letter State code, eg NY
text
USA,specifythe2letterStatecode,egNY
Item
specify the 2 letter State code, eg NY
text
Wheredidyoulivethelongest,othercountry,specify
Item
Other country, specify
text
Item
Smoked at least 100 cigarette (5 packs) during lifetime
text
C25180 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C20989 (NCI Thesaurus Property)
C29719 (NCI Thesaurus ObjectClass)
CL.10
Code List
Smoked at least 100 cigarette (5 packs) during lifetime
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, But Quit (Yes, but quit)
CL Item
Yes, Currently Smoke (Yes, currently smoke)
PatientInitialCigaretteSmokingAgeYearCount
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)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
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)
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)
Item
If you have had any of the illness listed below, please check yes for those that apply. (check = Yes 2)
text
CL.11
Code List
If you have had any of the illness listed below, please check yes for those that apply. (check = 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)
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)
Specifyother(illness)
Item
Specify other
text
Item Group
Family History
Brothers
Item
Brothers
text
Sisters
Item
Sisters
text
Sons
Item
Sons
text
Daughters
Item
Daughters
text
PatientAdoptedInd-3
Item
Are you adopted?
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)
Item
Blood relative with cancer
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.13
Code List
Blood relative with cancer
CL Item
Father (Father)
C25174 (NCI Thesaurus)
C0015671 (UMLS 2011AA)
CL Item
Mother (Mother)
C25189 (NCI Thesaurus)
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)
Item
Type of Cancer
text
CL.14
Code List
Type of Cancer
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Prostate (Prostate)
C12410 (NCI Thesaurus)
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)
specify(othercancers)
Item
Specify
text
CancerPreventionTrialKnowledgeDocumentedInd-2
Item
Have you ever heard of Cancer Prevention Trials?
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)
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)
CL.16
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- Never Would Consider (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)
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video