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ID

8984

Descripción

Quality of Life Core Questionnaire (Form 24-QLC) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA521D-9A9B-6310-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA521D-9A9B-6310-E034-0003BA12F5E7

Palabras clave

Versiones (2)
  1. 26/8/12 26/8/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
Subido en

9 de enero de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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    Breast Cancer NCT00659373 Quality of Life - Quality of Life Core Questionnaire (Form 24-QLC) - 2073639v3.0

    Inglés

    QUALITY OF LIFE CORE QUESTIONNAIRE (Form 24-QLC) Patient Instructions: We would like to know how strongly you are affected by your illness and treatment. Please answer all of the following questions by placing a vertical mark on the line depending on how you assess yourself. For example: Have you had trouble sleeping? None A lot This mark would indicate considerable sleeping difficulties. Your information will be treated as strictly confidential. Thank you for replying!

    1 formularios  
    How Have You Been Within The Last Two Weeks?
    Descripción

    How Have You Been Within The Last Two Weeks?

    Physical Well-Being
    Descripción

    PhysicalWell-Being

    Tipo de datos

    text

    Mood
    Descripción

    Mood

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664 (undefined)
    UMLS 2011AA ValueDomain
    C0349674 (Intellectual scale)
    SNOMED
    278111002
    Tiredness
    Descripción

    Tiredness

    Tipo de datos

    text

    Appetite
    Descripción

    Appetite

    Tipo de datos

    text

    Hot Flushes
    Descripción

    HotFlushes

    Tipo de datos

    text

    Feeling Sick (nausea/vomiting)
    Descripción

    FeelingSick

    Tipo de datos

    text

    How much effort does it cost you to cope with your illness?
    Descripción

    Howmucheffortdoesitcostyoutocopewithyourillness?

    Tipo de datos

    text

    Do you feel supported by the people close to you?
    Descripción

    Doyoufeelsupportedbythepeopleclosetoyou?

    Tipo de datos

    text

    Does the operation restrict the use of your arm?
    Descripción

    Doestheoperationrestricttheuseofyourarm?

    Tipo de datos

    text

    Imagine that you would have to live the rest of your life in your current condition. Please indicate, on the line below, how you would rate a life in your current condition between perfect health and worst health.Make a vertical mark according to your est
    Descripción

    Imaginethatyouwouldhavetolivetherestofyourlifeinyourcurrentcondition.Pleaseindicate,onthelinebelow,howyouwouldratealifeinyourcurrentconditionbetweenperfecthealthandworsthealth.Makeaverticalmarkaccordingtoyourest

    Tipo de datos

    text

    Ccrr Module For Quality Of Life Core Questionnaire (form 24-qlc)
    Descripción

    Ccrr Module For Quality Of Life Core Questionnaire (form 24-qlc)

    Patient ID Number (Study No.)
    Descripción

    PatientStudyID,CoordinatingGroup

    Tipo de datos

    text

    Patient Initials (f m fl sl)
    Descripción

    Patient Initials

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C2986440 (Person Initials)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25536 (undefined)
    Patient's Date of Birth (day)
    Descripción

    PatientBirthDate

    Tipo de datos

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25275 (undefined)
    UMLS 2011AA Property
    C2745955 (Occurrence)
    SNOMED
    246454002
    Participating Center/Affiliate
    Descripción

    MainMemberInstitution/Affiliate

    Tipo de datos

    text

    Center Code
    Descripción

    ParticipatingGroupCode

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162 (undefined)
    UMLS 2011AA ValueDomain
    C0805701 (Code)
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    Similar models

    QUALITY OF LIFE CORE QUESTIONNAIRE (Form 24-QLC) Patient Instructions: We would like to know how strongly you are affected by your illness and treatment. Please answer all of the following questions by placing a vertical mark on the line depending on how you assess yourself. For example: Have you had trouble sleeping? None A lot This mark would indicate considerable sleeping difficulties. Your information will be treated as strictly confidential. Thank you for replying!

    1 formularios
    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de datos
    Alias
    Item Group
    How Have You Been Within The Last Two Weeks?
    Item
    Physical Well-Being
    text
    CL.1
    Code List
    Physical Well-Being
    CL Item
    Good (Good)
    C0205170 (NCI Metathesaurus)
    CL Item
    Lousy (Lousy)
    Item
    Mood
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Mood
    CL Item
    Happy (Happy)
    CL Item
    Miserable (Miserable)
    Item
    Tiredness
    text
    CL.3
    Code List
    Tiredness
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    CL Item
    A Lot (A lot)
    Item
    Appetite
    text
    CL.4
    Code List
    Appetite
    CL Item
    Good (Good)
    C0205170 (NCI Metathesaurus)
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    Item
    Hot Flushes
    text
    CL.5
    Code List
    Hot Flushes
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    CL Item
    A Lot (A lot)
    Item
    Feeling Sick (nausea/vomiting)
    text
    CL.6
    Code List
    Feeling Sick (nausea/vomiting)
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    CL Item
    A Lot (A lot)
    Item
    How much effort does it cost you to cope with your illness?
    text
    CL.7
    Code List
    How much effort does it cost you to cope with your illness?
    CL Item
    No Effort At All (No effort at all)
    CL Item
    A Great Deal Of Effort (A great deal of effort)
    Item
    Do you feel supported by the people close to you?
    text
    CL.8
    Code List
    Do you feel supported by the people close to you?
    CL Item
    Very Much (Very much)
    C91217 (NCI Thesaurus)
    CL Item
    Not At All (Not at all)
    C91213 (NCI Thesaurus)
    Item
    Does the operation restrict the use of your arm?
    text
    CL.9
    Code List
    Does the operation restrict the use of your arm?
    CL Item
    Not At All (Not at all)
    C91213 (NCI Thesaurus)
    CL Item
    A Lot (A lot)
    Item
    Imagine that you would have to live the rest of your life in your current condition. Please indicate, on the line below, how you would rate a life in your current condition between perfect health and worst health.Make a vertical mark according to your est
    text
    CL.10
    Code List
    Imagine that you would have to live the rest of your life in your current condition. Please indicate, on the line below, how you would rate a life in your current condition between perfect health and worst health.Make a vertical mark according to your est
    CL Item
    Perfect Health (Perfect health)
    CL Item
    Worst Health (Worst health)
    Item Group
    Ccrr Module For Quality Of Life Core Questionnaire (form 24-qlc)
    PatientStudyID,CoordinatingGroup
    Item
    Patient ID Number (Study No.)
    text
    Patient Initials
    Item
    Patient Initials (f m fl sl)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    PatientBirthDate
    Item
    Patient's Date of Birth (day)
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    MainMemberInstitution/Affiliate
    Item
    Participating Center/Affiliate
    text
    ParticipatingGroupCode
    Item
    Center Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
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