ID

8984

Description

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

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer NCT00659373 Quality of Life - Quality of Life Core Questionnaire (Form 24-QLC) - 2073639v3.0

English

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 forms  
How Have You Been Within The Last Two Weeks?
Description

How Have You Been Within The Last Two Weeks?

Physical Well-Being
Description

PhysicalWell-Being

Data type

text

Mood
Description

Mood

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Tiredness
Description

Tiredness

Data type

text

Appetite
Description

Appetite

Data type

text

Hot Flushes
Description

HotFlushes

Data type

text

Feeling Sick (nausea/vomiting)
Description

FeelingSick

Data type

text

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

Howmucheffortdoesitcostyoutocopewithyourillness?

Data type

text

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

Doyoufeelsupportedbythepeopleclosetoyou?

Data type

text

Does the operation restrict the use of your arm?
Description

Doestheoperationrestricttheuseofyourarm?

Data type

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
Description

Imaginethatyouwouldhavetolivetherestofyourlifeinyourcurrentcondition.Pleaseindicate,onthelinebelow,howyouwouldratealifeinyourcurrentconditionbetweenperfecthealthandworsthealth.Makeaverticalmarkaccordingtoyourest

Data type

text

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

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

Patient ID Number (Study No.)
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (f m fl sl)
Description

Patient Initials

Data type

text

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

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Participating Center/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Center Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Back to the top of the page

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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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)
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial