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8516

Description

Z4032 UCSD - Shortness of Breath Questionnaire Surgery With or Without Internal Radiation Therapy in Treating Patients With Stage I Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F21FBFC2-16CA-105F-E034-0003BA3F9857

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F21FBFC2-16CA-105F-E034-0003BA3F9857

Mots-clés

Versions (2)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le

9 janvier 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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    Lung Cancer NCT00107172 Quality of Life - Z4032 UCSD - Shortness of Breath Questionnaire - 2306605v3.0

    Anglais

    No Instruction available.

    1 Formulaires  
    1. StudyEvent: Z4032 UCSD - Shortness of Breath Questionnaire
      1. No Instruction available.
    Header Module
    Description

    Header Module

    Visit
    Description

    AmericanCollegeofSurgeonsOncologyGroupVisitPeriodAmericanCollegeofSurgeonsOncologyGroupVisitPeriodType

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus ObjectClass
    C19712
    UMLS 2011AA ObjectClass
    C1515944
    NCI Thesaurus ObjectClass-2
    C25716
    UMLS 2011AA ObjectClass-2
    C0545082
    Patient ID (Pt. ID issued during registration or previously issued Patient ID)
    Description

    Patient Study ID

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    Institution ID
    Description

    Institution Number

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Patient Initials
    Description

    Patient Initials

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Institution
    Description

    Institution Name

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    How Short Of Breath Do You Get
    Description

    How Short Of Breath Do You Get

    At rest
    Description

    RestBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0443144
    Walking on a level at your own pace
    Description

    WalkFlatBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0560049
    Walking on a level with others your age
    Description

    WalkingBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0080331
    NCI Metathesaurus ObjectClass-2
    C0392680
    Walking up a hill
    Description

    WalkHillBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0580809
    Walking up stairs
    Description

    ClimbingStairsBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    CL299704
    NCI Metathesaurus ObjectClass-2
    C0392680
    While eating
    Description

    EatingBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0013470
    Standing up from a chair
    Description

    StandingUpBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0444796
    Brushing teeth
    Description

    ToothbrushingBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Thesaurus ObjectClass
    C63734
    UMLS 2011AA ObjectClass
    C0040461
    Shaving and/or brushing hair
    Description

    ShavingBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0522772
    Showering/bathing
    Description

    BathingBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0150141
    NCI Metathesaurus ObjectClass-2
    C0392680
    Dressing
    Description

    DressingBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    CL313791
    Picking up and straightening
    Description

    HouseCleaningBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0564042
    Doing dishes
    Description

    KitchenBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0557653
    Sweeping/vacuuming
    Description

    VacuumCleanerBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0392308
    Making bed
    Description

    MakeBedBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0564030
    Shopping
    Description

    ShoppingBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    CL112583
    Doing laundry
    Description

    LaundryBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0542293
    Washing car
    Description

    WashingBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0563947
    Mowing lawn
    Description

    LawnmowerBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0441054
    Watering lawn
    Description

    WaterBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0597678
    NCI Metathesaurus ObjectClass-2
    C0392680
    Sexual activities
    Description

    SexualActivityBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    CL197653
    How Much Do These Limit Your Daily Life
    Description

    How Much Do These Limit Your Daily Life

    Shortness of breath
    Description

    BreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    Fear of "hurting myself" by overexerting
    Description

    OverexertionBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0301616
    Fear of shortness of breath
    Description

    FearBreathShortnessAssessmentScale

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Metathesaurus ObjectClass
    C0392680
    NCI Metathesaurus ObjectClass-2
    C0015726
    Footer Module
    Description

    Footer Module

    Date Form Completed
    Description

    Date Form Completed

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1115437
    NCI Thesaurus ObjectClass
    C40988
    NCI Thesaurus Property
    C25250
    NCI Thesaurus ValueDomain-2
    C25367
    Retour au début de la page

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    1 Formulaires
    1. StudyEvent: Z4032 UCSD - Shortness of Breath Questionnaire
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Header Module
    Item
    Visit
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C19712 (NCI Thesaurus ObjectClass)
    C1515944 (UMLS 2011AA ObjectClass)
    C25716 (NCI Thesaurus ObjectClass-2)
    C0545082 (UMLS 2011AA ObjectClass-2)
    CL.1
    Code List
    Visit
    CL Item
    Month 12 (Month 12)
    CL Item
    Month 24 (Month 24)
    CL Item
    Month 3 (Month 3)
    CL Item
    Registration (Registration)
    C25646 (NCI Thesaurus)
    C1514821 (UMLS 2011AA)
    Patient Study ID
    Item
    Patient ID (Pt. ID issued during registration or previously issued Patient ID)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Institution Number
    Item
    Institution ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    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)
    Item Group
    How Short Of Breath Do You Get
    Item
    At rest
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0443144 (NCI Metathesaurus ObjectClass-2)
    CL.2
    Code List
    At rest
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Walking on a level at your own pace
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0560049 (NCI Metathesaurus ObjectClass-2)
    CL.3
    Code List
    Walking on a level at your own pace
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Walking on a level with others your age
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0080331 (NCI Metathesaurus ObjectClass)
    C0392680 (NCI Metathesaurus ObjectClass-2)
    CL.4
    Code List
    Walking on a level with others your age
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Walking up a hill
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0580809 (NCI Metathesaurus ObjectClass-2)
    CL.5
    Code List
    Walking up a hill
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Walking up stairs
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    CL299704 (NCI Metathesaurus ObjectClass)
    C0392680 (NCI Metathesaurus ObjectClass-2)
    CL.6
    Code List
    Walking up stairs
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    While eating
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0013470 (NCI Metathesaurus ObjectClass-2)
    CL.7
    Code List
    While eating
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Standing up from a chair
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0444796 (NCI Metathesaurus ObjectClass-2)
    CL.8
    Code List
    Standing up from a chair
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Brushing teeth
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C63734 (NCI Thesaurus ObjectClass)
    C0040461 (UMLS 2011AA ObjectClass)
    CL.9
    Code List
    Brushing teeth
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Shaving and/or brushing hair
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0522772 (NCI Metathesaurus ObjectClass-2)
    CL.10
    Code List
    Shaving and/or brushing hair
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Showering/bathing
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0150141 (NCI Metathesaurus ObjectClass)
    C0392680 (NCI Metathesaurus ObjectClass-2)
    CL.11
    Code List
    Showering/bathing
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Dressing
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    CL313791 (NCI Metathesaurus ObjectClass-2)
    CL.12
    Code List
    Dressing
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Picking up and straightening
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0564042 (NCI Metathesaurus ObjectClass-2)
    CL.13
    Code List
    Picking up and straightening
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Doing dishes
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0557653 (NCI Metathesaurus ObjectClass-2)
    CL.14
    Code List
    Doing dishes
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Sweeping/vacuuming
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0392308 (NCI Metathesaurus ObjectClass-2)
    CL.15
    Code List
    Sweeping/vacuuming
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Making bed
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0564030 (NCI Metathesaurus ObjectClass-2)
    CL.16
    Code List
    Making bed
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Shopping
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    CL112583 (NCI Metathesaurus ObjectClass-2)
    CL.17
    Code List
    Shopping
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Doing laundry
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0542293 (NCI Metathesaurus ObjectClass-2)
    CL.18
    Code List
    Doing laundry
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Washing car
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0563947 (NCI Metathesaurus ObjectClass-2)
    CL.19
    Code List
    Washing car
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Mowing lawn
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0441054 (NCI Metathesaurus ObjectClass-2)
    CL.20
    Code List
    Mowing lawn
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Watering lawn
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0597678 (NCI Metathesaurus ObjectClass)
    C0392680 (NCI Metathesaurus ObjectClass-2)
    CL.21
    Code List
    Watering lawn
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Sexual activities
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    CL197653 (NCI Metathesaurus ObjectClass-2)
    CL.22
    Code List
    Sexual activities
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item Group
    How Much Do These Limit Your Daily Life
    Item
    Shortness of breath
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    CL.23
    Code List
    Shortness of breath
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Fear of "hurting myself" by overexerting
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0301616 (NCI Metathesaurus ObjectClass-2)
    CL.24
    Code List
    Fear of "hurting myself" by overexerting
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item
    Fear of shortness of breath
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C0392680 (NCI Metathesaurus ObjectClass)
    C0015726 (NCI Metathesaurus ObjectClass-2)
    CL.25
    Code List
    Fear of shortness of breath
    CL Item
    Not At All (0)
    C91213 (NCI Thesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    Maximum (5)
    C25564 (NCI Thesaurus)
    C0806909 (UMLS 2011AA)
    Item Group
    Footer Module
    Date Form Completed
    Item
    Date Form Completed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1115437 (UMLS CUI-1)
    C40988 (NCI Thesaurus ObjectClass)
    C25250 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)
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