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ID

9516

Description

RTOG 0815 QL: Radiation Therapy Oncology Group Phase III Randomized Study of Dose- Escalated Radiotherapy With/Without STAD for Intermediate-Risk Prostate Cancer Radiation Therapy With or Without Androgen-Deprivation Therapy in Treating Patients With Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=65665DF7-C5B9-73E9-E040-BB89AD433B06

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=65665DF7-C5B9-73E9-E040-BB89AD433B06

Keywords

  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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    NCT00936390 Quality of Life - RTOG 0815 QL: Radiation Therapy Oncology Group Phase III Randomized Study of Dose- Escalated Radiotherapy With/Without STAD for Intermediate-Risk Prostate Cancer - 2852436v1.0

    No Instruction available.

    1. StudyEvent: RTOG 0815 QL: Radiation Therapy Oncology Group Phase III Randomized Study of Dose- Escalated Radiotherapy With/Without STAD for Intermediate-Risk Prostate Cancer
      1. No Instruction available.
    Unnamed Module 1
    Description

    Unnamed Module 1

    RTOG Study No.
    Description

    Protocol ID RTOG

    Data type

    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 #
    Description

    RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

    Data type

    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
    Description

    Institution Name

    Data type

    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.
    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
    Patient Initials
    Description

    Patient Initials

    Data type

    text

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

    Trial subject ID RTOG

    Data type

    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
    Description

    Data amended

    Data type

    boolean

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

    Unamed Module 2

    Time point of this assessment
    Description

    AssessmentPeriodType

    Data type

    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
    Other specify
    Description

    AssessmentPeriodSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C20989
    UMLS 2011AA ObjectClass
    C0031809
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    Calendar Due Date
    Description

    CalenderDueDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C19459
    UMLS 2011AA ObjectClass
    C1516147
    NCI Thesaurus Property
    C45263
    UMLS 2011AA Property
    C0678226
    Was patient questionnaire completed
    Description

    PatientQuestionnaireCompleteInd-2

    Data type

    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
    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
    Reason Questionnaire was not Completed
    Description

    Incomplete documentation, reason

    Data type

    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
    Description

    PatientRefuseIncompleteQuestionnaireSpecify

    Data type

    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
    Description

    PatientIncompleteQuestionnaireOtherSpecify

    Data type

    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
    Description

    PatientQuestionnaireCompleteMethodofCollectionType

    Data type

    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?
    Description

    PatientQuestionnaireAssistanceInd

    Data type

    text

    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
    Description

    PatientQuestionnaireAssistancePersonCategory

    Data type

    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 the assistance
    Description

    PatientQuestionnaireAssistanceType

    Data type

    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
    Description

    PatientQuestionnaireAssistanceCombinedSpecify

    Data type

    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
    Other, specify
    Description

    PatientQuestionnaireAssistanceOtherSpecify

    Data type

    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
    Comments
    Description

    Research Comments

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Signature of Person Completing This Form
    Description

    Responsible Person Signature

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25190
    NCI Thesaurus ObjectClass-2
    C25657
    NCI Thesaurus Property
    C25678
    Date Form Originally Completed
    Description

    Form Completion Date

    Data type

    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
    Exercise
    Description

    Exercise

    Times per week
    Description

    QualityofLifeMildExercisePerformedAssessmentWeekFrequency

    Data type

    float

    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25217
    UMLS 2011AA Property
    C1516048
    NCI Thesaurus Property-2
    C70666
    UMLS 2011AA Property-2
    C2945599
    NCI Thesaurus Property-3
    C38000
    UMLS 2011AA Property-3
    C0884358
    NCI Thesaurus Property-4
    C16567
    UMLS 2011AA Property-4
    C0015259
    NCI Thesaurus ValueDomain
    C29844
    UMLS 2011AA ValueDomain
    C0439230
    NCI Thesaurus ValueDomain-2
    C25515
    UMLS 2011AA ValueDomain-2
    C0439603
    Average duration
    Description

    QualityofLifeMildExercisePerformedAssessmentDuration

    Data type

    float

    Measurement units
    • min
    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25217
    UMLS 2011AA Property
    C1516048
    NCI Thesaurus Property-2
    C70666
    UMLS 2011AA Property-2
    C2945599
    NCI Thesaurus Property-3
    C38000
    UMLS 2011AA Property-3
    C0884358
    NCI Thesaurus Property-4
    C16567
    UMLS 2011AA Property-4
    C0015259
    NCI Thesaurus ValueDomain
    C25330
    UMLS 2011AA ValueDomain
    C0449238
    min
    Times per week
    Description

    QualityofLifeModerateExercisePerformedAssessmentWeekFrequency

    Data type

    float

    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25217
    UMLS 2011AA Property
    C1516048
    NCI Thesaurus Property-2
    C38000
    UMLS 2011AA Property-2
    C0884358
    NCI Thesaurus Property-3
    C61376
    UMLS 2011AA Property-3
    C1881878
    NCI Thesaurus Property-4
    C16567
    UMLS 2011AA Property-4
    C0015259
    NCI Thesaurus ValueDomain
    C29844
    UMLS 2011AA ValueDomain
    C0439230
    NCI Thesaurus ValueDomain-2
    C25515
    UMLS 2011AA ValueDomain-2
    C0439603
    Average duration
    Description

    QualityofLifeModerateExercisePerformedAssessmentDuration

    Data type

    float

    Measurement units
    • min
    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25217
    UMLS 2011AA Property
    C1516048
    NCI Thesaurus Property-2
    C38000
    UMLS 2011AA Property-2
    C0884358
    NCI Thesaurus Property-3
    C61376
    UMLS 2011AA Property-3
    C1881878
    NCI Thesaurus Property-4
    C16567
    UMLS 2011AA Property-4
    C0015259
    NCI Thesaurus ValueDomain
    C25330
    UMLS 2011AA ValueDomain
    C0449238
    min
    Times per week
    Description

    QualityofLifeHighExercisePerformedAssessmentWeekFrequency

    Data type

    float

    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25217
    UMLS 2011AA Property
    C1516048
    NCI Thesaurus Property-2
    C38000
    UMLS 2011AA Property-2
    C0884358
    NCI Thesaurus Property-3
    C25227
    UMLS 2011AA Property-3
    C0205250
    NCI Thesaurus Property-4
    C16567
    UMLS 2011AA Property-4
    C0015259
    NCI Thesaurus ValueDomain
    C29844
    UMLS 2011AA ValueDomain
    C0439230
    NCI Thesaurus ValueDomain-2
    C25515
    UMLS 2011AA ValueDomain-2
    C0439603
    Average duration
    Description

    QualityofLifeHighExercisePerformedAssessmentDuration

    Data type

    float

    Measurement units
    • min
    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25217
    UMLS 2011AA Property
    C1516048
    NCI Thesaurus Property-2
    C38000
    UMLS 2011AA Property-2
    C0884358
    NCI Thesaurus Property-3
    C25227
    UMLS 2011AA Property-3
    C0205250
    NCI Thesaurus Property-4
    C16567
    UMLS 2011AA Property-4
    C0015259
    NCI Thesaurus ValueDomain
    C25330
    UMLS 2011AA ValueDomain
    C0449238
    min
    I have been experiencing generalized muscle weakness over the last week
    Description

    QualityofLifeMuscleWeaknessAssessmentScore

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25217
    UMLS 2011AA Property
    C1516048
    NCI Thesaurus Property-2
    C50658
    UMLS 2011AA Property-2
    C0151786
    NCI Thesaurus ValueDomain
    C25338
    UMLS 2011AA ValueDomain
    C0449820
    During the past week, how would you rate your sleep quality overall
    Description

    QualityofLifeSleepQualityAssessmentScore

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25217
    UMLS 2011AA Property
    C1516048
    NCI Thesaurus Property-2
    C73425
    UMLS 2011AA Property-2
    C0037313
    NCI Thesaurus Property-3
    C25283
    UMLS 2011AA Property-3
    C0332306
    NCI Thesaurus ValueDomain
    C25338
    UMLS 2011AA ValueDomain
    C0449820

    Similar models

    No Instruction available.

    1. StudyEvent: RTOG 0815 QL: Radiation Therapy Oncology Group Phase III Randomized Study of Dose- Escalated Radiotherapy With/Without STAD for Intermediate-Risk Prostate Cancer
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    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 of this assessment
    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)
    Code List
    Time point of this assessment
    CL Item
    Pretreatment (Pretreatment)
    CL Item
    Third Week Of Radiation Therapy (Third week of RT)
    CL Item
    Last Week Of Radiation Therapy (Last week of RT)
    CL Item
    6 Months Of Radiation Therapy (6 months after RT)
    CL Item
    12 Months After Radiation Therapy (12 months after RT)
    CL Item
    60 Months After Radiation Therapy (60 months after RT)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    AssessmentPeriodSpecify
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus ObjectClass)
    C0031809 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    CalenderDueDate
    Item
    Calendar Due Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C19459 (NCI Thesaurus ObjectClass)
    C1516147 (UMLS 2011AA ObjectClass)
    C45263 (NCI Thesaurus Property)
    C0678226 (UMLS 2011AA Property)
    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)
    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)
    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)
    Item
    Did the patient require any assistance in completing the questionnaire?
    text
    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)
    Code List
    Did the patient require any assistance in completing the questionnaire?
    CL Item
    Not Applicable (Not applicable)
    C48660 (NCI Thesaurus)
    C1272460 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Unknown If Assistance Given (Unknown if assistance given)
    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)
    Code List
    Specify the person who assisted the patient
    CL Item
    Not Applicable (Not applicable)
    C48660 (NCI Thesaurus)
    C1272460 (UMLS 2011AA)
    CL Item
    Staff Member (Staff member)
    CL Item
    Family (Family)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    Item
    Extent of the assistance
    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)
    Code List
    Extent of the assistance
    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)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (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)
    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)
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    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)
    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)
    Item Group
    Exercise
    QualityofLifeMildExercisePerformedAssessmentWeekFrequency
    Item
    Times per week
    float
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25217 (NCI Thesaurus Property)
    C1516048 (UMLS 2011AA Property)
    C70666 (NCI Thesaurus Property-2)
    C2945599 (UMLS 2011AA Property-2)
    C38000 (NCI Thesaurus Property-3)
    C0884358 (UMLS 2011AA Property-3)
    C16567 (NCI Thesaurus Property-4)
    C0015259 (UMLS 2011AA Property-4)
    C29844 (NCI Thesaurus ValueDomain)
    C0439230 (UMLS 2011AA ValueDomain)
    C25515 (NCI Thesaurus ValueDomain-2)
    C0439603 (UMLS 2011AA ValueDomain-2)
    QualityofLifeMildExercisePerformedAssessmentDuration
    Item
    Average duration
    float
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25217 (NCI Thesaurus Property)
    C1516048 (UMLS 2011AA Property)
    C70666 (NCI Thesaurus Property-2)
    C2945599 (UMLS 2011AA Property-2)
    C38000 (NCI Thesaurus Property-3)
    C0884358 (UMLS 2011AA Property-3)
    C16567 (NCI Thesaurus Property-4)
    C0015259 (UMLS 2011AA Property-4)
    C25330 (NCI Thesaurus ValueDomain)
    C0449238 (UMLS 2011AA ValueDomain)
    QualityofLifeModerateExercisePerformedAssessmentWeekFrequency
    Item
    Times per week
    float
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25217 (NCI Thesaurus Property)
    C1516048 (UMLS 2011AA Property)
    C38000 (NCI Thesaurus Property-2)
    C0884358 (UMLS 2011AA Property-2)
    C61376 (NCI Thesaurus Property-3)
    C1881878 (UMLS 2011AA Property-3)
    C16567 (NCI Thesaurus Property-4)
    C0015259 (UMLS 2011AA Property-4)
    C29844 (NCI Thesaurus ValueDomain)
    C0439230 (UMLS 2011AA ValueDomain)
    C25515 (NCI Thesaurus ValueDomain-2)
    C0439603 (UMLS 2011AA ValueDomain-2)
    QualityofLifeModerateExercisePerformedAssessmentDuration
    Item
    Average duration
    float
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25217 (NCI Thesaurus Property)
    C1516048 (UMLS 2011AA Property)
    C38000 (NCI Thesaurus Property-2)
    C0884358 (UMLS 2011AA Property-2)
    C61376 (NCI Thesaurus Property-3)
    C1881878 (UMLS 2011AA Property-3)
    C16567 (NCI Thesaurus Property-4)
    C0015259 (UMLS 2011AA Property-4)
    C25330 (NCI Thesaurus ValueDomain)
    C0449238 (UMLS 2011AA ValueDomain)
    QualityofLifeHighExercisePerformedAssessmentWeekFrequency
    Item
    Times per week
    float
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25217 (NCI Thesaurus Property)
    C1516048 (UMLS 2011AA Property)
    C38000 (NCI Thesaurus Property-2)
    C0884358 (UMLS 2011AA Property-2)
    C25227 (NCI Thesaurus Property-3)
    C0205250 (UMLS 2011AA Property-3)
    C16567 (NCI Thesaurus Property-4)
    C0015259 (UMLS 2011AA Property-4)
    C29844 (NCI Thesaurus ValueDomain)
    C0439230 (UMLS 2011AA ValueDomain)
    C25515 (NCI Thesaurus ValueDomain-2)
    C0439603 (UMLS 2011AA ValueDomain-2)
    QualityofLifeHighExercisePerformedAssessmentDuration
    Item
    Average duration
    float
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25217 (NCI Thesaurus Property)
    C1516048 (UMLS 2011AA Property)
    C38000 (NCI Thesaurus Property-2)
    C0884358 (UMLS 2011AA Property-2)
    C25227 (NCI Thesaurus Property-3)
    C0205250 (UMLS 2011AA Property-3)
    C16567 (NCI Thesaurus Property-4)
    C0015259 (UMLS 2011AA Property-4)
    C25330 (NCI Thesaurus ValueDomain)
    C0449238 (UMLS 2011AA ValueDomain)
    Item
    I have been experiencing generalized muscle weakness over the last week
    text
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25217 (NCI Thesaurus Property)
    C1516048 (UMLS 2011AA Property)
    C50658 (NCI Thesaurus Property-2)
    C0151786 (UMLS 2011AA Property-2)
    C25338 (NCI Thesaurus ValueDomain)
    C0449820 (UMLS 2011AA ValueDomain)
    Code List
    I have been experiencing generalized muscle weakness over the last week
    CL Item
    0 (0)
    C0919414 (NCI Metathesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    Item
    During the past week, how would you rate your sleep quality overall
    text
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25217 (NCI Thesaurus Property)
    C1516048 (UMLS 2011AA Property)
    C73425 (NCI Thesaurus Property-2)
    C0037313 (UMLS 2011AA Property-2)
    C25283 (NCI Thesaurus Property-3)
    C0332306 (UMLS 2011AA Property-3)
    C25338 (NCI Thesaurus ValueDomain)
    C0449820 (UMLS 2011AA ValueDomain)
    Code List
    During the past week, how would you rate your sleep quality overall
    CL Item
    0 (0)
    C0919414 (NCI Metathesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)

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