ID
9332
Beschreibung
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
Stichworte
Versionen (5)
- 27.08.12 27.08.12 -
- 11.08.14 11.08.14 - Martin Dugas
- 11.08.14 11.08.14 - Martin Dugas
- 11.08.14 11.08.14 - Martin Dugas
- 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am
9. Januar 2015
DOI
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Lizenz
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
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
- StudyEvent: NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B)
Beschreibung
Time Point
Beschreibung
CaseReportFormPersonCompleteType
Datentyp
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
Beschreibung
QualityofLifeCompleteAssessmentDate
Datentyp
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
Beschreibung
Section 1 - Lifetime Medical Conditions
Beschreibung
ChronicDiseasePresentType
Datentyp
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
Beschreibung
DiseaseorDisorderPhysicianCareAssessmentAssessmentInd-3
Datentyp
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
Beschreibung
PatientMedicalConditionTherapyInd-2
Datentyp
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
Beschreibung
PersonDiseaseorDisorderActivityRestrictionAssessmentInd-3
Datentyp
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
Beschreibung
Section 2 - Tobacco Usage
Beschreibung
Smoking history
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1519384
- NCI Thesaurus ObjectClass
- C17934
- NCI Thesaurus Property
- C18772
Beschreibung
Tobaccootheruseindicator
Datentyp
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
Beschreibung
OtherTobaccoUseType
Datentyp
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
Beschreibung
PatientInitialCigaretteSmokingAgeYearCount
Datentyp
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
Beschreibung
Smoking history
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C1519384
- NCI Thesaurus ObjectClass
- C17934
- NCI Thesaurus Property
- C18772
Beschreibung
CurrentSmokingHistoryType
Datentyp
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
Beschreibung
Smoker amount smoked
Datentyp
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
Beschreibung
Section 3 - Alcohol Consumption
Beschreibung
AlcoholLifetimeHistoryIndicator
Datentyp
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
Beschreibung
AlcoholUseLifetimeInd
Datentyp
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
Beschreibung
AlcoholConsumptionPastYearIndicator
Datentyp
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
Beschreibung
AlcoholCurrentUseRangeType
Datentyp
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
Beschreibung
AlcoholAverageDailyUseType
Datentyp
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
Beschreibung
AlcoholDrinkUseWeekNumber
Datentyp
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
Ähnliche Modelle
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
- StudyEvent: NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
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)
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)
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)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
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)
C0205394 (UMLS 2011AA)
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)
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)
C0006826 (UMLS 2011AA)
C0018802 (UMLS 2011AA)
C0011570 (UMLS 2011AA)
C0011849 (UMLS 2011AA)
C0010068 (UMLS 2011AA)
C0022646 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
C0023884 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
C2709248 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
C0029408 (UMLS 2011AA)
C0003811 (UMLS 2011AA)
C0003873 (UMLS 2011AA)
C0040132 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
C0041582 (UMLS 2011AA)
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)
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)
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)
C1519384 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C18772 (NCI Thesaurus Property)
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)
C0332307 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
C0182504 (UMLS 2011AA)
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)
C1519384 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C18772 (NCI Thesaurus Property)
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)
C1608325 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C0449865 (NCI Metathesaurus Property)
C25473 (NCI Thesaurus ValueDomain)
C25515 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C1522602 (UMLS 2011AA ValueDomain)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
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)
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)
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)
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)