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ID

9175

Beskrivning

GOG-0249 Comorbid Illness Reporting Form Pelvic Radiation Therapy or Vaginal Implant Radiation Therapy, Paclitaxel, and Carboplatin in Treating Patients With High-Risk Stage I or Stage II Endometrial Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4FF32E53-FBDB-394B-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4FF32E53-FBDB-394B-E044-0003BA3F9857

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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    Endometrial Cancer NCT00807768 On-Study - GOG-0249 Comorbid Illness Reporting Form - 2760082v1.0

    No Instruction available.

    1. StudyEvent: GOG-0249 Comorbid Illness Reporting Form
      1. No Instruction available.
    Header Module
    Beskrivning

    Header Module

    Date form originally completed (m d y)
    Beskrivning

    Form Completion Date

    Datatyp

    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
    Date form amended (m d y)
    Beskrivning

    Amendment date

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-1
    C0680532
    NCI Thesaurus Property
    C25250
    UMLS CUI-2
    C0011008
    NCI Thesaurus Property-2
    C25416
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Person amending form, last name
    Beskrivning

    Person Amending Form

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25190
    UMLS CUI-2
    C1547383
    NCI Thesaurus Property
    C25364
    Patient Initials (first, middle, last)
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Patient Study ID
    Beskrivning

    Patient ID GOG

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1512288
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25521
    Person Completing Form, Last Name
    Beskrivning

    Person Completing Form Last Name

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass-2
    C25657
    UMLS CUI-2
    C1301584
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25551
    NCI Thesaurus ValueDomain
    C25191
    Personal Medical History
    Beskrivning

    Personal Medical History

    Current Medical Conditions
    Beskrivning

    PatientMedicalConditionCurrentType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25261
    UMLS 2011AA Property
    C0205476
    NCI Thesaurus Property-2
    C25457
    UMLS 2011AA Property-2
    C0348080
    History of comorbid condition
    Beskrivning

    PatientPre-ExistingConditionInd-3

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Metathesaurus Property
    CL232826
    Is the patient currently taking medication for this illness or has the patient had a surgical intervention for this illness within the last 12 months
    Beskrivning

    SurgicalProcedureMedicationPriorMedicalConditionReceivedInd-3

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    NCI Thesaurus ObjectClass-2
    C459
    UMLS 2011AA ObjectClass-2
    C0013227
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus Property-2
    C25639
    UMLS 2011AA Property-2
    C1514756
    NCI Thesaurus Property-3
    C25261
    UMLS 2011AA Property-3
    C0205476
    NCI Thesaurus Property-4
    C25457
    UMLS 2011AA Property-4
    C0348080
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Comments
    Beskrivning

    Comments

    COMMENTS
    Beskrivning

    Research Comments

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393

    Similar models

    No Instruction available.

    1. StudyEvent: GOG-0249 Comorbid Illness Reporting Form
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Header Module
    Form Completion Date
    Item
    Date form originally completed (m d y)
    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)
    Amendment date
    Item
    Date form amended (m d y)
    date
    C19464 (NCI Thesaurus ObjectClass)
    C0680532 (UMLS CUI-1)
    C25250 (NCI Thesaurus Property)
    C0011008 (UMLS CUI-2)
    C25416 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Person Amending Form
    Item
    Person amending form, last name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25190 (NCI Thesaurus ObjectClass)
    C1547383 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Patient Initials
    Item
    Patient Initials (first, middle, last)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Patient ID GOG
    Item
    Patient Study ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1512288 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25521 (NCI Thesaurus Property-2)
    Person Completing Form Last Name
    Item
    Person Completing Form, Last Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass-2)
    C1301584 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    C25191 (NCI Thesaurus ValueDomain)
    Item Group
    Personal Medical History
    Item
    Current Medical Conditions
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25261 (NCI Thesaurus Property)
    C0205476 (UMLS 2011AA Property)
    C25457 (NCI Thesaurus Property-2)
    C0348080 (UMLS 2011AA Property-2)
    Code List
    Current Medical Conditions
    CL Item
    Hypertension (hypertension)
    C3117 (NCI Thesaurus)
    C0020538 (UMLS 2011AA)
    CL Item
    Diabetes (diabetes)
    CL Item
    Coronary Artery Disease (Coronary artery disease)
    CL Item
    Angina (Angina)
    C51221 (NCI Thesaurus)
    C0002962 (UMLS 2011AA)
    CL Item
    Myocardial Infarction (Myocardial Infarction)
    C27996 (NCI Thesaurus)
    C0027051 (UMLS 2011AA)
    CL Item
    Peripheral Vascular Disease (peripheral vascular disease)
    CL Item
    Cerebral Vascular Accident (Cerebral vascular accident)
    CL Item
    Transient Ischemic Attack (Transient Ischemic Attack)
    CL Item
    Waist Circumference >= 35 Inches (Waist circumference >= 35 inches)
    CL Item
    Drug Treatment For Increasing Triglycerides (Drug treatment for increasing triglycerides)
    CL Item
    Drug Treatment For Decreasing Hdl-c Level (Drug treatment for decreasing HDL-C level)
    CL Item
    Drug Treatment For Hypertension (Drug treatment for hypertension)
    CL Item
    Drug Treatment For Increasing Glucose Level (Drug treatment for increasing glucose level)
    Item
    History of comorbid condition
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    CL232826 (NCI Metathesaurus Property)
    Code List
    History of comorbid condition
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Is the patient currently taking medication for this illness or has the patient had a surgical intervention for this illness within the last 12 months
    text
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    C459 (NCI Thesaurus ObjectClass-2)
    C0013227 (UMLS 2011AA ObjectClass-2)
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C25639 (NCI Thesaurus Property-2)
    C1514756 (UMLS 2011AA Property-2)
    C25261 (NCI Thesaurus Property-3)
    C0205476 (UMLS 2011AA Property-3)
    C25457 (NCI Thesaurus Property-4)
    C0348080 (UMLS 2011AA Property-4)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    Code List
    Is the patient currently taking medication for this illness or has the patient had a surgical intervention for this illness within the last 12 months
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item Group
    Comments
    Research Comments
    Item
    COMMENTS
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)

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