ID

9332

Description

NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B) A Randomized Phase III Trial of Adjuvant Therapy Comparing Chemotherapy Alone (Six Cycles of Docetaxel Plus Cyclophosphamide or Four Cycles of Doxorubicin Plus Cyclophosphamide Followed by Weekly Paclitaxel) to Chemotherapy Plus Trastuzumab in Women With Node- Positive or High-Risk Node-Negative HER2-Low Invasive Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=96C1751F-BCDC-2B10-E040-BB89AD433A9B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=96C1751F-BCDC-2B10-E040-BB89AD433A9B

Keywords

Versions (5)
  1. 8/27/12 8/27/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 8/11/14 8/11/14 - Martin Dugas
  4. 8/11/14 8/11/14 - Martin Dugas
  5. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT01275677 Quality of Life - NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B) - 3165170v1.0

English

INSTRUCTIONS TO THE INSTITUTION This questionnaire should be completed by all patients. This form should be completed after the patient has signed the B-47 consent forms, but before randomization. A clinical staff member should complete page 1, print the patient's initials at the top of Pages 2 through 5, and give the questionnaire to the patient for completion. After the patient has completed the questionnaire, verify that the date the questionnaire was completed is recorded at the top of page 2. After the patient has been randomized, print the NSABP Patient ID at the top of pages 2 through 5 and fax all 5 pages to the NSABP Biostatistical Center at (412) 622-2115

1 forms  
Header
Description

Header

Patient Initials (Last First Middle)
Description

Patient Initials

Data type

text

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

Patient ID NSABP

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1513905
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C15818
Institution/Affiliate
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass-2
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
Institution Number
Description

Institution Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Staff member administering form, Last Name
Description

PersonFormAdministrationLastName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain-2
C25551
UMLS 2011AA ValueDomain-2
C1517741
Staff member administering form, first name
Description

PersonFormAdministrationFirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain-2
C25509
UMLS 2011AA ValueDomain-2
C1279901
Staff Member Administering Form, Phone
Description

PersonFormAdministrationPhoneNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus Property-2
C25409
UMLS 2011AA Property-2
C1533734
Are data amended (If yes, check the box and circle amended items)
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Time Point
Description

Time Point

This form is being filled out (mark one)
Description

CaseReportFormPersonCompleteType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property-2
C25250
UMLS 2011AA Property-2
C0205197
Date Questionnaire Completed (Month Day Year)
Description

QualityofLifeCompleteAssessmentDate

Data type

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-2
C25367
Section 1 - Lifetime Medical Conditions
Description

Section 1 - Lifetime Medical Conditions

Problem
Description

ChronicDiseasePresentType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass-2
C14141
UMLS 2011AA ObjectClass-2
C0205191
Have you ever seen a doctor for the problem?
Description

DiseaseorDisorderPhysicianCareAssessmentAssessmentInd-3

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25741
UMLS 2011AA Property
C0031831
NCI Thesaurus Property-2
C25217
UMLS 2011AA Property-2
C1516048
NCI Thesaurus Property-3
C61488
UMLS 2011AA Property-3
C1947933
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Do you currently receive treatment for it?
Description

PatientMedicalConditionTherapyInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
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
Does it now limit your activities?
Description

PersonDiseaseorDisorderActivityRestrictionAssessmentInd-3

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C43431
UMLS 2011AA Property
C0441655
NCI Thesaurus Property-3
C2991
UMLS 2011AA Property-2
C0012634
NCI Thesaurus Property-4
C53452
UMLS 2011AA Property-3
C0443288
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Section 2 - Tobacco Usage
Description

Section 2 - Tobacco Usage

Have you smoked at least 100 cigarettes in your entire life? (100 cigarettes = 5 packs)
Description

Smoking history

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1519384
NCI Thesaurus ObjectClass
C17934
NCI Thesaurus Property
C18772
Have you used other forms of tobacco regularly
Description

Tobaccootheruseindicator

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass-2
C891
UMLS 2011AA ObjectClass-2
C0040329
NCI Thesaurus ObjectClass-3
C691
UMLS 2011AA ObjectClass-3
C0028040
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Have you used other forms of tobacco regularly (Check all that apply)
Description

OtherTobaccoUseType

Data type

text

Alias
NCI Thesaurus Property
C25284
UMLS 2011AA Property
C0332307
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C891
UMLS 2011AA ObjectClass
C0040329
How old were you when you started using tobacco (In years)
Description

PatientInitialCigaretteSmokingAgeYearCount

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property-2
C18270
UMLS 2011AA Property-2
C0700219
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Did you use tobacco (In the past week)
Description

Smoking history

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C1519384
NCI Thesaurus ObjectClass
C17934
NCI Thesaurus Property
C18772
On about how many days did you use tobacco (During the period of your life when you used tobacco, think about a typical month)
Description

CurrentSmokingHistoryType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25471
UMLS 2011AA ObjectClass
C0521116
NCI Thesaurus ObjectClass-2
C17934
UMLS 2011AA ObjectClass-2
C0453996
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
On the days you did smoke, what was the average number of cigarettes you smoked per day (Think about a typical month when you smoked cigarettes)
Description

Smoker amount smoked

Data type

text

Alias
NCI Thesaurus ObjectClass
C17934
UMLS CUI-1
C1608325
NCI Thesaurus Property
C25471
NCI Metathesaurus Property
C0449865
NCI Thesaurus ValueDomain
C25473
NCI Thesaurus ValueDomain-2
C25515
Section 3 - Alcohol Consumption
Description

Section 3 - Alcohol Consumption

During your entire life, have you had at least 12 drinks of any kind of alcoholic beverage? ([this includes beer 1 bottle/can, wine 1 glass, and hard liquor 1 cocktail or 1 shot of liquor])
Description

AlcoholLifetimeHistoryIndicator

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ObjectClass
C2190
UMLS 2011AA ObjectClass
C0001962
In any one year have you had at least 12 drinks of any kind of alcoholic beverage (this includes beer, wine, and hard liquor)
Description

AlcoholUseLifetimeInd

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C2190
UMLS 2011AA ObjectClass
C0001962
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
In the last 12 months have you had at least 12 drinks of any kind of alcoholic beverage (this includes beer, wine, and hard liquor)
Description

AlcoholConsumptionPastYearIndicator

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C2190
UMLS 2011AA ObjectClass
C0001962
NCI Thesaurus Property
C29848
UMLS 2011AA Property
C0439234
NCI Thesaurus Property-2
C25340
UMLS 2011AA Property-2
C0457083
NCI Thesaurus Property-3
C25609
UMLS 2011AA Property-3
C1444637
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
On about how many days did you have at least one drink of alcohol (In the last 12 months when you drank alcohol, think about a typical month)
Description

AlcoholCurrentUseRangeType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus ObjectClass
C2190
UMLS 2011AA ObjectClass
C0001962
NCI Thesaurus Property-2
C25340
UMLS 2011AA Property-2
C0457083
On the days when you drank, about how many drinks did you have on average
Description

AlcoholAverageDailyUseType

Data type

text

Alias
NCI Thesaurus ObjectClass
C2190
UMLS 2011AA ObjectClass
C0001962
NCI Thesaurus Property
C25473
UMLS 2011AA Property
C0332173
NCI Thesaurus Property-2
C37917
UMLS 2011AA Property-2
C1510992
NCI Thesaurus Property-3
C25340
UMLS 2011AA Property-3
C0457083
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
How many drinks of any kind of alcoholic beverage have you had in the last week
Description

AlcoholDrinkUseWeekNumber

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus ObjectClass
C2190
UMLS 2011AA ObjectClass
C0001962
NCI Thesaurus Property-2
C25340
UMLS 2011AA Property-2
C0457083
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INSTRUCTIONS TO THE INSTITUTION This questionnaire should be completed by all patients. This form should be completed after the patient has signed the B-47 consent forms, but before randomization. A clinical staff member should complete page 1, print the patient's initials at the top of Pages 2 through 5, and give the questionnaire to the patient for completion. After the patient has completed the questionnaire, verify that the date the questionnaire was completed is recorded at the top of page 2. After the patient has been randomized, print the NSABP Patient ID at the top of pages 2 through 5 and fax all 5 pages to the NSABP Biostatistical Center at (412) 622-2115

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Patient Initials
Item
Patient Initials (Last First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Institution Number
Item
Institution Number
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
PersonFormAdministrationLastName
Item
Staff member administering form, Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)
PersonFormAdministrationFirstName
Item
Staff member administering form, first name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25509 (NCI Thesaurus ValueDomain-2)
C1279901 (UMLS 2011AA ValueDomain-2)
PersonFormAdministrationPhoneNumber
Item
Staff Member Administering Form, Phone
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
Data amended
Item
Are data amended (If yes, check the box and circle amended items)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Time Point
Item
This form is being filled out (mark one)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property-2)
C0205197 (UMLS 2011AA Property-2)
CL.2
Code List
This form is being filled out (mark one)
CL Item
By Clinical Staff On Phone With Participant (By clinical staff on phone with participant)
CL Item
By Patient In Doctor's Office (By participant in doctor's office)
CL Item
By Participant Not In Doctor's Office (By participant not in doctor's office)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
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-2)
Item Group
Section 1 - Lifetime Medical Conditions
Item
Problem
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)
CL.3
Code List
Problem
CL Item
Anemia (Anemia or other blood disease)
E10010 (CTCAE)
CL Item
Atrial Fibrillation (Atrial fibrillation)
E10081 (CTCAE)
CL Item
Back Pain (Back pain)
E12388 (CTCAE)
CL Item
Osteoporosis (Bone loss or osteoporosis)
E12508 (CTCAE)
CL Item
Malignant Neoplasm (Cancer (other than breast or non-melanoma skin cancer))
C9305 (NCI Thesaurus)
C0006826 (UMLS 2011AA)
CL Item
Congestive Heart Failure (Congestive Heart Failure)
C3080 (NCI Thesaurus)
C0018802 (UMLS 2011AA)
CL Item
Depression (Depression)
C2982 (NCI Thesaurus)
C0011570 (UMLS 2011AA)
CL Item
Diabetes Mellitus (Diabetes)
C2985 (NCI Thesaurus)
C0011849 (UMLS 2011AA)
CL Item
Myocardial Infarction (Heart attack (myocardial infarction))
E10152 (CTCAE)
CL Item
Coronary Disease (Heart disease)
C26732 (NCI Thesaurus)
C0010068 (UMLS 2011AA)
CL Item
Hypertension (High blood pressure)
E13785 (CTCAE)
CL Item
Disease Or Disorder Kidney (Kidney disease)
C12415 (NCI Thesaurus)
C0022646 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
CL Item
Disease Or Disorder Liver (Liver disease)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
CL Item
Disease Or Disorder Pulmonary (Lung disease)
C13304 (NCI Thesaurus)
C2709248 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
CL Item
Osteoarthritis (Osteoarthritis, degenerative arthritis)
C3293 (NCI Thesaurus)
C0029408 (UMLS 2011AA)
CL Item
Arrhythmia (Other heart rhythm problem)
C2881 (NCI Thesaurus)
C0003811 (UMLS 2011AA)
CL Item
Rheumatoid Arthritis (Rheumatoid Arthritis)
C2884 (NCI Thesaurus)
C0003873 (UMLS 2011AA)
CL Item
Stroke (Stroke)
E12826 (CTCAE)
CL Item
Disease Or Disorder Thyroid Gland (Thyroid disease)
C12400 (NCI Thesaurus)
C0040132 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
CL Item
Ulcer (Ulcer or stomach disease)
C3426 (NCI Thesaurus)
C0041582 (UMLS 2011AA)
DiseaseorDisorderPhysicianCareAssessmentAssessmentInd-3
Item
Have you ever seen a doctor for the problem?
boolean
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25741 (NCI Thesaurus Property)
C0031831 (UMLS 2011AA Property)
C25217 (NCI Thesaurus Property-2)
C1516048 (UMLS 2011AA Property-2)
C61488 (NCI Thesaurus Property-3)
C1947933 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
PatientMedicalConditionTherapyInd-2
Item
Do you currently receive treatment for it?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (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)
PersonDiseaseorDisorderActivityRestrictionAssessmentInd-3
Item
Does it now limit your activities?
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C43431 (NCI Thesaurus Property-2)
C0441655 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property-3)
C0012634 (UMLS 2011AA Property-2)
C53452 (NCI Thesaurus Property-4)
C0443288 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Item Group
Section 2 - Tobacco Usage
Smoking history
Item
Have you smoked at least 100 cigarettes in your entire life? (100 cigarettes = 5 packs)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C18772 (NCI Thesaurus Property)
Tobaccootheruseindicator
Item
Have you used other forms of tobacco regularly
boolean
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C891 (NCI Thesaurus ObjectClass-2)
C0040329 (UMLS 2011AA ObjectClass-2)
C691 (NCI Thesaurus ObjectClass-3)
C0028040 (UMLS 2011AA ObjectClass-3)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
Have you used other forms of tobacco regularly (Check all that apply)
text
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
CL.9
Code List
Have you used other forms of tobacco regularly (Check all that apply)
CL Item
Chew Tobacco (Chew tobacco)
CL Item
Cigar (Cigar)
C1813 (NCI Thesaurus)
C0182504 (UMLS 2011AA)
CL Item
Pipe (Pipe)
CL Item
Other, Specify (Other, specify)
PatientInitialCigaretteSmokingAgeYearCount
Item
How old were you when you started using tobacco (In years)
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property-2)
C0700219 (UMLS 2011AA Property-2)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item
Did you use tobacco (In the past week)
text
C25284 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C18772 (NCI Thesaurus Property)
CL.10
Code List
Did you use tobacco (In the past week)
CL Item
No, Not At All (No, not at all)
CL Item
Yes, Every Day (Yes, every day)
CL Item
Yes, Some Days (Yes, some days)
Item
On about how many days did you use tobacco (During the period of your life when you used tobacco, think about a typical month)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C17934 (NCI Thesaurus ObjectClass-2)
C0453996 (UMLS 2011AA ObjectClass-2)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
CL.11
Code List
On about how many days did you use tobacco (During the period of your life when you used tobacco, think about a typical month)
CL Item
1 - 2 Days (1 - 2 days)
CL Item
3 - 5 Days (3 - 5 days)
CL Item
6 - 9 Days (6 - 9 days)
CL Item
10 - 19 Days (10 - 19 days)
CL Item
20 - 29 Days (20 - 29 days)
CL Item
Every Day (Every day)
Item
On the days you did smoke, what was the average number of cigarettes you smoked per day (Think about a typical month when you smoked cigarettes)
text
C17934 (NCI Thesaurus ObjectClass)
C1608325 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C0449865 (NCI Metathesaurus Property)
C25473 (NCI Thesaurus ValueDomain)
C25515 (NCI Thesaurus ValueDomain-2)
CL.12
Code List
On the days you did smoke, what was the average number of cigarettes you smoked per day (Think about a typical month when you smoked cigarettes)
CL Item
Fewer Than 10 Cigarettes (Fewer than 10 cigarettes)
CL Item
10 To 20 Cigarettes (10 to 20 cigarettes)
CL Item
More Than 20 Cigarettes (More than 20 cigarettes)
Item Group
Section 3 - Alcohol Consumption
AlcoholLifetimeHistoryIndicator
Item
During your entire life, have you had at least 12 drinks of any kind of alcoholic beverage? ([this includes beer 1 bottle/can, wine 1 glass, and hard liquor 1 cocktail or 1 shot of liquor])
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
AlcoholUseLifetimeInd
Item
In any one year have you had at least 12 drinks of any kind of alcoholic beverage (this includes beer, wine, and hard liquor)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
AlcoholConsumptionPastYearIndicator
Item
In the last 12 months have you had at least 12 drinks of any kind of alcoholic beverage (this includes beer, wine, and hard liquor)
boolean
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus Property)
C0439234 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
C25609 (NCI Thesaurus Property-3)
C1444637 (UMLS 2011AA Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
On about how many days did you have at least one drink of alcohol (In the last 12 months when you drank alcohol, think about a typical month)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
CL.16
Code List
On about how many days did you have at least one drink of alcohol (In the last 12 months when you drank alcohol, think about a typical month)
CL Item
1 - 2 Days (1 - 2 days)
CL Item
3 - 5 Days (3 - 5 days)
CL Item
6 - 9 Days (6 - 9 days)
CL Item
10 - 19 Days (10 - 19 days)
CL Item
20 - 29 Days (20 - 29 days)
CL Item
Every Day (Every day)
Item
On the days when you drank, about how many drinks did you have on average
text
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25473 (NCI Thesaurus Property)
C0332173 (UMLS 2011AA Property)
C37917 (NCI Thesaurus Property-2)
C1510992 (UMLS 2011AA Property-2)
C25340 (NCI Thesaurus Property-3)
C0457083 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.17
Code List
On the days when you drank, about how many drinks did you have on average
CL Item
Less Than 1 Drink Per Day (Less than 1 drink per day)
CL Item
1 - 2 Per Day (1 - 2 per day)
CL Item
3 - 5 Per Day (3 - 5 per day)
CL Item
6+ Per Day (6+ per day)
AlcoholDrinkUseWeekNumber
Item
How many drinks of any kind of alcoholic beverage have you had in the last week
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
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