ID

860

Beskrivning

NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C893003F-B432-7480-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C893003F-B432-7480-E034-0003BA12F5E7

Nyckelord

Versioner (3)
  1. 2012-08-26 2012-08-26 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-07-05 2015-07-05 -
Uppladdad den

26 augusti 2012

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00087178 Pre-Study - NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire - 2175263v3.0

Engelsk

(For all B-36 Patients)

1 Formulär  
  1. StudyEvent: NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire
    1. (For all B-36 Patients)
Unnamed1
Beskrivning

Unnamed1

Patient Initials (Last, First Middle)
Beskrivning

PatientInitialsName

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NSABP Patient ID
Beskrivning

PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C15818
UMLS 2011AA Property
C1513905
Unnamed2
Beskrivning

Unnamed2

Date Questionnaire Completed (Month Day Year)
Beskrivning

QualityofLifeCompleteAssessmentDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25367
Unnamed3
Beskrivning

Unnamed3

NSABP Patient ID
Beskrivning

PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C15818
UMLS 2011AA Property
C1513905
Section A
Beskrivning

Section A

Have you had your uterus removed?
Beskrivning

UterusRemovedInd-3

Datatyp

text

Have you had both your ovaries removed?
Beskrivning

OvaryRemovedInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C12404
UMLS 2011AA ObjectClass
C0029939
NCI Thesaurus Property
C25650
UMLS 2011AA Property
C0849355
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
Beskrivning

MensesOccurrenceInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ObjectClass
C3232
UMLS 2011AA ObjectClass
C0025344
Section B
Beskrivning

Section B

When was your last menstrual period (or vaginal bleeding)? (Month Year)
Beskrivning

Firstdayoflastmenstrualperiod

Datatyp

text

Did your periods stop or become less frequent during the last 12 months?
Beskrivning

MensesEndOccurrenceInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ObjectClass
C3232
UMLS 2011AA ObjectClass
C0025344
NCI Thesaurus Property
C25496
UMLS 2011AA Property
C2746065
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
Beskrivning

HormoneReplacementTherapyAdministeredInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15599
UMLS 2011AA ObjectClass
C0282402
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
Beskrivning

HormoneTherapyContraceptionAdministeredInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15445
UMLS 2011AA ObjectClass
C0279025
NCI Thesaurus Property
C37932
UMLS 2011AA Property
C0700589
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Ccrr Module For Nsabp Protocol B-36 Baseline Menstrual History Questionnaire
Beskrivning

Ccrr Module For Nsabp Protocol B-36 Baseline Menstrual History Questionnaire

Tillbaka till toppen

Similar models

(For all B-36 Patients)

1 Formulär
  1. StudyEvent: NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire
    1. (For all B-36 Patients)
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Unnamed1
PatientInitialsName
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C15818 (NCI Thesaurus Property)
C1513905 (UMLS 2011AA Property)
Item Group
Unnamed2
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed (Month Day Year)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
Item Group
Unnamed3
PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C15818 (NCI Thesaurus Property)
C1513905 (UMLS 2011AA Property)
Item Group
Section A
Item
Have you had your uterus removed?
text
CL.1
Code List
Have you had your uterus removed?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you had both your ovaries removed?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12404 (NCI Thesaurus ObjectClass)
C0029939 (UMLS 2011AA ObjectClass)
C25650 (NCI Thesaurus Property)
C0849355 (UMLS 2011AA Property)
CL.2
Code List
Have you had both your ovaries removed?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C3232 (NCI Thesaurus ObjectClass)
C0025344 (UMLS 2011AA ObjectClass)
CL.3
Code List
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Section B
Firstdayoflastmenstrualperiod
Item
When was your last menstrual period (or vaginal bleeding)? (Month Year)
text
Item
Did your periods stop or become less frequent during the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C3232 (NCI Thesaurus ObjectClass)
C0025344 (UMLS 2011AA ObjectClass)
C25496 (NCI Thesaurus Property)
C2746065 (UMLS 2011AA Property)
CL.4
Code List
Did your periods stop or become less frequent during the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15599 (NCI Thesaurus ObjectClass)
C0282402 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.5
Code List
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
Item
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C37932 (NCI Thesaurus Property)
C0700589 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.6
Code List
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
Item Group
Ccrr Module For Nsabp Protocol B-36 Baseline Menstrual History Questionnaire
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