ID

9511

Beskrivning

RTOG-0617 FA: Radiation Therapy Oncology Group Phase III High-dose Vs Standard-dose Conformal XRT with Chemotherapy Functinal Assessment Trial Outcome Index (TOI) Form High-Dose or Standard-Dose Radiation Therapy and Chemotherapy With or Without Cetuximab in Treating Patients With Newly Diagnosed Stage III Non-Small Cell Lung Cancer That Cannot Be Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=24E78551-175E-6260-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=24E78551-175E-6260-E044-0003BA3F9857

Nyckelord

Versioner (5)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-01-09 2015-01-09 - Martin Dugas
  4. 2015-07-08 2015-07-08 -
  5. 2021-09-20 2021-09-20 -
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00533949 Quality of Life - RTOG-0617 FA: Radiation Therapy Oncology Group Phase III High-dose Vs Standard-dose Conformal XRT with Chemotherapy Functinal Assessment Trial Outcome Index (TOI) Form - 2555824v1.0

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: RTOG-0617 FA: Radiation Therapy Oncology Group Phase III High-dose Vs Standard-dose Conformal XRT with Chemotherapy Functinal Assessment Trial Outcome Index (TOI) Form
    1. No Instruction available.
Unnamed Module 1
Beskrivning

Unnamed Module 1

RTOG Study No.
Beskrivning

Protocol ID RTOG

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Case #
Beskrivning

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C19778
UMLS 2011AA ObjectClass-2
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C49152
UMLS 2011AA Property-2
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Beskrivning

Institution Name

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Institution No.
Beskrivning

Institution Number

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Patient Initials
Beskrivning

Patient Initials

Datatyp

text

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

Trial subject ID RTOG

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Amended data
Beskrivning

Data amended

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Unamed Module 2
Beskrivning

Unamed Module 2

Time point
Beskrivning

AssessmentPeriodType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Was patient questionnaire completed
Beskrivning

PatientQuestionnaireCompleteInd-2

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property-2
C17048
UMLS 2011AA Property-2
C0034394
Date patient questionnaire completed
Beskrivning

QualityofLifeCompleteAssessmentDate

Datatyp

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
Reason Questionnaire was not Completed
Beskrivning

Incomplete documentation, reason

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS CUI-1
C1548386
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C0566251
NCI Metathesaurus Property
C0034394
Patient refused for other reason, specify
Beskrivning

PatientRefuseIncompleteQuestionnaireSpecify

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property-2
C49161
UMLS 2011AA Property-2
C1705116
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Other reason, specify
Beskrivning

PatientIncompleteQuestionnaireOtherSpecify

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C17649
UMLS 2011AA ValueDomain-2
C0205394
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
Specify method of completion
Beskrivning

PatientQuestionnaireCompleteMethodofCollectionType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property-2
C17048
UMLS 2011AA Property-2
C0034394
Did the patient require any assistance in completing the questionnaire?
Beskrivning

PatientQuestionnaireAssistanceInd

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
Specify the person who assisted the patient
Beskrivning

PatientQuestionnaireAssistancePersonCategory

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25190
UMLS 2011AA ValueDomain
C0027361
NCI Thesaurus ValueDomain-2
C25372
UMLS 2011AA ValueDomain-2
C0683312
Extent of assistance given
Beskrivning

PatientQuestionnaireAssistanceType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
Combination of above, specify
Beskrivning

PatientQuestionnaireAssistanceCombinedSpecify

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C25454
UMLS 2011AA ValueDomain-2
C0205195
COMMENTS
Beskrivning

Research Comments

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Other, specify
Beskrivning

PatientQuestionnaireAssistanceOtherSpecify

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C17649
UMLS 2011AA ValueDomain-2
C0205394
Date form originally completed
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
Signature of Person Completing This Form
Beskrivning

Responsible Person Signature

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C25657
NCI Thesaurus Property
C25678
Physical Well-being
Beskrivning

Physical Well-being

I have a lack of energy
Beskrivning

PatientEnergyAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C48058
UMLS 2011AA Property-2
C0542479
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I have nausea
Beskrivning

PatientNauseaAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3258
UMLS 2011AA Property-2
C0027497
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
Because of my physical condition, I have trouble meeting the needs of my family
Beskrivning

PatientGeneralPhysicalConditionAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
CL104641
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I have pain
Beskrivning

PatientPainAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3303
UMLS 2011AA Property-2
C0030193
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am bothered by side effects of treatment
Beskrivning

PatientAdverseEventAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C41331
UMLS 2011AA Property-2
C0877248
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I feel ill
Beskrivning

PatientMalaiseAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3832
UMLS 2011AA Property-2
C0231218
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am forced to spend time in bed
Beskrivning

PatientBedRestAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Functional Well-being
Beskrivning

Functional Well-being

I am able to work (include work at home)
Beskrivning

AbilityPatientWorkAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0085732
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0043227
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
My work (including work at home) is fulfilling
Beskrivning

SatisfactionPatientWorkAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C62185
UMLS 2011AA Property
C0242428
NCI Metathesaurus Property
C0043227
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am able to enjoy life
Beskrivning

PatientEnjoymentofLifeAssessmentQualityofLifeAssessment

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
CL196329
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I have accepted my illness
Beskrivning

Ihaveacceptedmyillness

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am sleeping well
Beskrivning

Iamsleepingwell

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am enjoying the things I usually do for fun
Beskrivning

IamenjoyingthethingsIusuallydoforfun

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am content with the quality of my life right now
Beskrivning

Iamcontentwiththequalityofmyliferightnow

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Additional Concerns
Beskrivning

Additional Concerns

I have been short of breath
Beskrivning

QualityofLifeDyspneaEvaluationScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property-2
C2998
UMLS 2011AA Property-2
C0013404
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am losing weight
Beskrivning

PatientWeightLossAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3445
UMLS 2011AA Property-2
C0043096
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
My thinking is clear
Beskrivning

Mythinkingisclear

Datatyp

text

I have been coughing
Beskrivning

Ihavebeencoughing

Datatyp

text

I am bothered by hair loss.
Beskrivning

HairAssessmentResponseType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25755
UMLS 2011AA Property
C0871261
I have a good appetite
Beskrivning

PatientAppetiteAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C25152
UMLS 2011AA Property-2
C0003618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I feel tightness in my chest
Beskrivning

Ifeeltightnessinmychest

Datatyp

text

Breathing is easy for me
Beskrivning

Breathingiseasyforme

Datatyp

text

Have you ever smoked?
Beskrivning

TobaccoSmokingHistoryIndicator

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
I regret my smoking
Beskrivning

PatientSmokingDepressionAssessmentScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
NCI Thesaurus Property-2
C2982
UMLS 2011AA Property-2
C0011570
NCI Metathesaurus Property
C0037369
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
COMMENTS
Beskrivning

Research Comments

Datatyp

text

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

Person Completing Form

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Date form originally completed
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
Tillbaka till toppen

Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: RTOG-0617 FA: Radiation Therapy Oncology Group Phase III High-dose Vs Standard-dose Conformal XRT with Chemotherapy Functinal Assessment Trial Outcome Index (TOI) Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Unnamed Module 1
Protocol ID RTOG
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass-2)
C1514695 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property-2)
C1706256 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Institution Number
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Data amended
Item
Amended data
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Unamed Module 2
Item
Time point
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.2
Code List
Time point
CL Item
At Completion Of Chemoradiation (At completion of chemoradiation)
CL Item
Pretreatment (Pretreatment)
CL Item
Three Months From Baseline (Three months from baseline)
CL Item
Twelve Months From Baseline (Twelve months from baseline)
CL Item
Twenty-four Months From Baseline (Twenty-four months from baseline)
PatientQuestionnaireCompleteInd-2
Item
Was patient questionnaire completed
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C17048 (NCI Thesaurus Property-2)
C0034394 (UMLS 2011AA Property-2)
QualityofLifeCompleteAssessmentDate
Item
Date patient questionnaire completed
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
Reason Questionnaire was not Completed
text
C25638 (NCI Thesaurus ValueDomain)
C1548386 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C0566251 (UMLS CUI-2)
C0034394 (NCI Metathesaurus Property)
CL.4
Code List
Reason Questionnaire was not Completed
CL Item
Not Applicable, Questionnaire Was Completed (Not applicable, questionnaire was completed)
CL Item
Patient Refused Due To Illness (Patient refused due to illness)
CL Item
Patient Refused For Other Reason (Patient refused for other reason)
CL Item
Patient Unable To Be Contacted (Patient unable to be contacted)
CL Item
Institution Error (Institutional error)
CL Item
Tool Not Availalble In Patient's Language (Tool not availalble in patient's language)
CL Item
Other Reason (Other reason)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientRefuseIncompleteQuestionnaireSpecify
Item
Patient refused for other reason, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C49161 (NCI Thesaurus Property-2)
C1705116 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
PatientIncompleteQuestionnaireOtherSpecify
Item
Other reason, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
Item
Specify method of completion
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C17048 (NCI Thesaurus Property-2)
C0034394 (UMLS 2011AA Property-2)
CL.5
Code List
Specify method of completion
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
At Appointment (At appointment)
CL Item
By Mail (By mail)
CL Item
By Telephone (By telephone)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientQuestionnaireAssistanceInd
Item
Did the patient require any assistance in completing the questionnaire?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
Item
Specify the person who assisted the patient
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25190 (NCI Thesaurus ValueDomain)
C0027361 (UMLS 2011AA ValueDomain)
C25372 (NCI Thesaurus ValueDomain-2)
C0683312 (UMLS 2011AA ValueDomain-2)
CL.7
Code List
Specify the person who assisted the patient
CL Item
Staff Member (Staff member)
CL Item
Family (Family)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item
Extent of assistance given
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
CL.8
Code List
Extent of assistance given
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Read Items To Patient (Read items to patient)
CL Item
Interpreted Items For Patient (Interpreted items for patient)
CL Item
Marked Items Per Patient's Response (Marked items per patient's response)
CL Item
Combination Of Above (Combination of above)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientQuestionnaireAssistanceCombinedSpecify
Item
Combination of above, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25454 (NCI Thesaurus ValueDomain-2)
C0205195 (UMLS 2011AA ValueDomain-2)
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
PatientQuestionnaireAssistanceOtherSpecify
Item
Other, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
Form Completion Date
Item
Date form originally completed
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)
Responsible Person Signature
Item
Signature of Person Completing This Form
text
C25704 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C25678 (NCI Thesaurus Property)
Item Group
Physical Well-being
Item
I have a lack of energy
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C48058 (NCI Thesaurus Property-2)
C0542479 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.9
Code List
I have a lack of energy
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I have nausea
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3258 (NCI Thesaurus Property-2)
C0027497 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.10
Code List
I have nausea
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
Because of my physical condition, I have trouble meeting the needs of my family
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL104641 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.11
Code List
Because of my physical condition, I have trouble meeting the needs of my family
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I have pain
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3303 (NCI Thesaurus Property-2)
C0030193 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.12
Code List
I have pain
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am bothered by side effects of treatment
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C41331 (NCI Thesaurus Property-2)
C0877248 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.13
Code List
I am bothered by side effects of treatment
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I feel ill
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3832 (NCI Thesaurus Property-2)
C0231218 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.14
Code List
I feel ill
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am forced to spend time in bed
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL.15
Code List
I am forced to spend time in bed
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item Group
Functional Well-being
Item
I am able to work (include work at home)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0085732 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0043227 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.16
Code List
I am able to work (include work at home)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
My work (including work at home) is fulfilling
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C62185 (NCI Thesaurus Property-2)
C0242428 (UMLS 2011AA Property)
C0043227 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.17
Code List
My work (including work at home) is fulfilling
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am able to enjoy life
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL196329 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.18
Code List
I am able to enjoy life
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I have accepted my illness
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.19
Code List
I have accepted my illness
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am sleeping well
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.20
Code List
I am sleeping well
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am enjoying the things I usually do for fun
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.21
Code List
I am enjoying the things I usually do for fun
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am content with the quality of my life right now
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.22
Code List
I am content with the quality of my life right now
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item Group
Additional Concerns
Item
I have been short of breath
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C2998 (NCI Thesaurus Property-2)
C0013404 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.23
Code List
I have been short of breath
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am losing weight
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3445 (NCI Thesaurus Property-2)
C0043096 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.24
Code List
I am losing weight
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
My thinking is clear
text
CL.25
Code List
My thinking is clear
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I have been coughing
text
CL.26
Code List
I have been coughing
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I am bothered by hair loss.
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
CL.27
Code List
I am bothered by hair loss.
CL Item
2 (A little bit)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
1 (Not at all)
C91213 (NCI Thesaurus)
CL Item
4 (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
3 (Somewhat)
CL Item
5 (Very much)
C91217 (NCI Thesaurus)
Item
I have a good appetite
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25152 (NCI Thesaurus Property-2)
C0003618 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.28
Code List
I have a good appetite
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I feel tightness in my chest
text
CL.29
Code List
I feel tightness in my chest
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
Breathing is easy for me
text
CL.30
Code List
Breathing is easy for me
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
TobaccoSmokingHistoryIndicator
Item
Have you ever smoked?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
Item
I regret my smoking
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C2982 (NCI Thesaurus Property-2)
C0011570 (UMLS 2011AA Property-2)
C0037369 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.32
Code List
I regret my smoking
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Person Completing Form
Item
Completed by
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Form Completion Date
Item
Date form originally completed
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)
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