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9400

Description

Southwest Oncology Group BASELINE ASSESSMENT FORM (S0230) Goserelin in Preventing Ovarian Failure in Women Receiving Chemotherapy for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BEA4E960-6745-0470-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BEA4E960-6745-0470-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Breast Cancer NCT00068601 Pre-Study - Southwest Oncology Group BASELINE ASSESSMENT FORM (S0230) - 2170664v3.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Southwest Oncology Group BASELINE ASSESSMENT FORM (S0230)
      1. No Instruction available.
    Baseline Conditions
    Description

    Baseline Conditions

    Assessment Date
    Description

    AssessmentDate

    Data type

    date

    Conditions
    Description

    CTC Adverse Event Term

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C41331
    UMLS CUI-1
    C1516728
    NCI Thesaurus Property
    C25703
    UMLS CUI-2
    C2826934
    CTC GRADE
    Description

    CTC Adverse Event Grade

    Data type

    float

    Alias
    NCI Thesaurus ObjectClass
    C41331
    UMLS CUI-1
    C2985911
    NCI Thesaurus Property
    C25365
    Other conditions (specify using CTC Terminology
    Description

    CTCAdverseEventTermSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C41331
    UMLS 2011AA ObjectClass
    C0877248
    NCI Thesaurus Property
    C25703
    UMLS 2011AA Property
    C1515273
    Does the patient have bone mineral loss?
    Description

    Hasthepatientexperiencedbonemineralloss?

    Data type

    text

    Yes, specify Grade
    Description

    Yes,specifyGrade

    Data type

    text

    Comments
    Description

    Research Comments

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Ccrr Module For Southwest Oncology Group Baseline Assessment Form (s0230)
    Description

    Ccrr Module For Southwest Oncology Group Baseline Assessment Form (s0230)

    SWOG Patient ID
    Description

    Trial subject ID SWOG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    Patient Initials (L, F, M)
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Insitution/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
    Physician
    Description

    Investigator Name

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2826892
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C17089
    NCI Thesaurus ObjectClass-2
    C25644
    Group Name
    Description

    Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2347449
    NCI Thesaurus ObjectClass
    C25608
    NCI Thesaurus ObjectClass-2
    C17005
    NCI Thesaurus Property
    C25364
    Study No.
    Description

    Study Number Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Pt. ID
    Description

    Trial subject ID Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: Southwest Oncology Group BASELINE ASSESSMENT FORM (S0230)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Baseline Conditions
    AssessmentDate
    Item
    Assessment Date
    date
    Item
    Conditions
    text
    C41331 (NCI Thesaurus ObjectClass)
    C1516728 (UMLS CUI-1)
    C25703 (NCI Thesaurus Property)
    C2826934 (UMLS CUI-2)
    CL.1
    Code List
    Conditions
    CL Item
    Menopausal Symptoms (Hot Flashes)
    CL Item
    Sweating Increased (Sweating)
    C0700590 (NCI Metathesaurus)
    CL Item
    Anxiety Nec (Anxiety/agitation)
    CL Item
    Depression Nec (Depression)
    CL Item
    Headache Nos (Headache)
    CL Item
    Libido Decreased (Libido loss)
    C0011124 (NCI Metathesaurus)
    CL Item
    Vulvovaginal Dryness (Vaginal dryness)
    CL036720 (NCI Metathesaurus)
    CTC Adverse Event Grade
    Item
    CTC GRADE
    float
    C41331 (NCI Thesaurus ObjectClass)
    C2985911 (UMLS CUI-1)
    C25365 (NCI Thesaurus Property)
    CTCAdverseEventTermSpecify
    Item
    Other conditions (specify using CTC Terminology
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus ObjectClass)
    C0877248 (UMLS 2011AA ObjectClass)
    C25703 (NCI Thesaurus Property)
    C1515273 (UMLS 2011AA Property)
    Item
    Does the patient have bone mineral loss?
    text
    CL.3
    Code List
    Does the patient have bone mineral loss?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, Specify Grade (Yes, specify Grade)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Yes,specifyGrade
    Item
    Yes, specify Grade
    text
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Item Group
    Ccrr Module For Southwest Oncology Group Baseline Assessment Form (s0230)
    Trial subject ID SWOG
    Item
    SWOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Patient Initials
    Item
    Patient Initials (L, F, M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Institution Name
    Item
    Insitution/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)
    Investigator Name
    Item
    Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2826892 (UMLS CUI-1)
    C25364 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    C25644 (NCI Thesaurus ObjectClass-2)
    Participating Group
    Item
    Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2347449 (UMLS CUI-1)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Pt. ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
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