ID

9535

Description

RTOG 0920 Phase III Head and Neck Cancer Dermatology Life Quality Index Form (DL) Radiation Therapy With or Without Cetuximab in Treating Patients Who Have Undergone Surgery for Locally Advanced Head and Neck Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5DDB9090-D79C-C15F-E040-BB89A6435310

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5DDB9090-D79C-C15F-E040-BB89A6435310

Keywords

Versions (3)
  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
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT00956007 Quality of Life - RTOG 0920 Phase III Head and Neck Cancer Dermatology Life Quality Index Form (DL) - 2815438v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: RTOG 0920 Phase III Head and Neck Cancer Dermatology Life Quality Index Form (DL)
    1. No Instruction available.
Header
Description

Header

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
Unnamed2
Description

Unnamed2

Amended Data (This sheet is the cover page used for submission of the DLQ - questionnaire. This page must be completed by the medical staff nurse, data manager, physician, etc.)
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
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
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 (MM DD YYYY)
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
Other, specify
Description

PatientQuestionnaireAssistancePersonSpecify

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
C25190
UMLS 2011AA ValueDomain-2
C0027361
Extent of assistance given
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
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 Completed (MM DD YYYY)
Description

Date Form Completed

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
Dermatology Life Quality Index
Description

Dermatology Life Quality Index

Over the last week, how itchy, sore, painful or stinging has your skin been
Description

SkinQualityofLifeDiscomfortAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C50535
UMLS 2011AA Property
C0234215
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, how embarrassed or self conscious have you been because of your skin
Description

SkinQualityofLifeNegativeEmotionActivityAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C25247
UMLS 2011AA Property
C0205160
NCI Thesaurus Property-3
C54266
UMLS 2011AA Property-2
C0013987
NCI Thesaurus Property-4
C43431
UMLS 2011AA Property-3
C0441655
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden
Description

SkinQualityofLifeDisruptionActivityAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C43431
UMLS 2011AA Property
C0441655
NCI Thesaurus Property-3
C25486
UMLS 2011AA Property-2
C0332453
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, how much has your skin influenced the clothes you wear
Description

SkinQualityofLifeOuterCoverAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C38166
UMLS 2011AA Property
C0205101
NCI Thesaurus Property-3
C68811
UMLS 2011AA Property-2
C1999244
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, how much has your skin affected any social or leisure activities
Description

SkinQualityofLifeSocialEventParticipationAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property-2
C25367
NCI Thesaurus Property-3
C25499
UMLS 2011AA Property-2
C0441471
NCI Thesaurus Property-4
C62650
UMLS 2011AA Property-3
C0728831
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, how much has your skin made it difficult for you to do any sport
Description

SkinQualityofLifeExerciseParticipationAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property-2
C25367
NCI Thesaurus Property-3
C16567
UMLS 2011AA Property-2
C0015259
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, has your skin prevented you from working or studying
Description

SkinQualityofLifeReducedWorkActivityAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C25640
UMLS 2011AA Property
C0392756
NCI Thesaurus Property-3
C43431
UMLS 2011AA Property-2
C0441655
NCI Thesaurus Property-4
C74299
UMLS 2011AA Property-3
C0043227
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week how much has your skin been a problem at work or studying
Description

SkinQualityofLifeWorkActivityProblemAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C43431
UMLS 2011AA Property
C0441655
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-4
C74299
UMLS 2011AA Property-3
C0043227
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives
Description

SkinQualityofLifeDisruptionRelationshipSatisfactionAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C62185
UMLS 2011AA Property
C0242428
NCI Thesaurus Property-3
C25486
UMLS 2011AA Property-2
C0332453
NCI Thesaurus Property-4
C25648
UMLS 2011AA Property-3
C0439849
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, how much has your skin caused any sexual difficulties
Description

SkinQualityofLifeSexBehaviorDifficultyAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C17127
UMLS 2011AA Property
C0036864
NCI Thesaurus Property-3
C62189
UMLS 2011AA Property-2
C1299586
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time
Description

SkinQualityofLifeTreatmentRelationshipDifficultyAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12470
UMLS 2011AA ObjectClass-2
C1123023
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C25648
UMLS 2011AA Property
C0439849
NCI Thesaurus Property-3
C15368
NCI Thesaurus Property-4
C62189
UMLS 2011AA Property-2
C1299586
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
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1 forms
  1. StudyEvent: RTOG 0920 Phase III Head and Neck Cancer Dermatology Life Quality Index Form (DL)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
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)
Item Group
Unnamed2
Data amended
Item
Amended Data (This sheet is the cover page used for submission of the DLQ - questionnaire. This page must be completed by the medical staff nurse, data manager, physician, etc.)
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
Baseline (baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
CL Item
1 Year From Start Of Treatment (1 year from start of treatment)
CL Item
18 Months From Start Of Treatment (18 months from start of treatment)
CL Item
2 Years From Start Of Treatment (2 years from start of treatment)
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 (MM DD YYYY)
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 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 available in patient's language)
CL Item
Patient Refused For Other Reason (Patient refused for other reason)
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)
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)
CL.6
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)
CL.7
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)
PatientQuestionnaireAssistancePersonSpecify
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)
C25190 (NCI Thesaurus ValueDomain-2)
C0027361 (UMLS 2011AA ValueDomain-2)
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)
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)
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)
Date Form Completed
Item
Date Form Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Item Group
Dermatology Life Quality Index
Item
Over the last week, how itchy, sore, painful or stinging has your skin been
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C50535 (NCI Thesaurus Property-2)
C0234215 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.9
Code List
Over the last week, how itchy, sore, painful or stinging has your skin been
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
Item
Over the last week, how embarrassed or self conscious have you been because of your skin
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C25247 (NCI Thesaurus Property-2)
C0205160 (UMLS 2011AA Property)
C54266 (NCI Thesaurus Property-3)
C0013987 (UMLS 2011AA Property-2)
C43431 (NCI Thesaurus Property-4)
C0441655 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.10
Code List
Over the last week, how embarrassed or self conscious have you been because of your skin
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
Item
Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C43431 (NCI Thesaurus Property-2)
C0441655 (UMLS 2011AA Property)
C25486 (NCI Thesaurus Property-3)
C0332453 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.11
Code List
Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Not Relevant (Not relevant)
Item
Over the last week, how much has your skin influenced the clothes you wear
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C38166 (NCI Thesaurus Property-2)
C0205101 (UMLS 2011AA Property)
C68811 (NCI Thesaurus Property-3)
C1999244 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.12
Code List
Over the last week, how much has your skin influenced the clothes you wear
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Not Relevant (Not relevant)
Item
Over the last week, how much has your skin affected any social or leisure activities
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C25499 (NCI Thesaurus Property-3)
C0441471 (UMLS 2011AA Property-2)
C62650 (NCI Thesaurus Property-4)
C0728831 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.13
Code List
Over the last week, how much has your skin affected any social or leisure activities
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Not Relevant (Not relevant)
Item
Over the last week, how much has your skin made it difficult for you to do any sport
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C16567 (NCI Thesaurus Property-3)
C0015259 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.14
Code List
Over the last week, how much has your skin made it difficult for you to do any sport
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Not Relevant (Not relevant)
Item
Over the last week, has your skin prevented you from working or studying
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C25640 (NCI Thesaurus Property-2)
C0392756 (UMLS 2011AA Property)
C43431 (NCI Thesaurus Property-3)
C0441655 (UMLS 2011AA Property-2)
C74299 (NCI Thesaurus Property-4)
C0043227 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.15
Code List
Over the last week, has your skin prevented you from working or studying
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Not Relevant (Not relevant)
Item
Over the last week how much has your skin been a problem at work or studying
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C43431 (NCI Thesaurus Property-2)
C0441655 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-2)
C74299 (NCI Thesaurus Property-4)
C0043227 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.16
Code List
Over the last week how much has your skin been a problem at work or studying
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
Item
Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C62185 (NCI Thesaurus Property-2)
C0242428 (UMLS 2011AA Property)
C25486 (NCI Thesaurus Property-3)
C0332453 (UMLS 2011AA Property-2)
C25648 (NCI Thesaurus Property-4)
C0439849 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.17
Code List
Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Not Relevant (Not relevant)
Item
Over the last week, how much has your skin caused any sexual difficulties
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C17127 (NCI Thesaurus Property-2)
C0036864 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property-3)
C1299586 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.18
Code List
Over the last week, how much has your skin caused any sexual difficulties
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Not Relevant (Not relevant)
Item
Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12470 (NCI Thesaurus ObjectClass-2)
C1123023 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C25648 (NCI Thesaurus Property-2)
C0439849 (UMLS 2011AA Property)
C15368 (NCI Thesaurus Property-3)
C62189 (NCI Thesaurus Property-4)
C1299586 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.19
Code List
Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
CL Item
A Lot (A lot)
CL Item
A Little (A little)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Not Relevant (Not relevant)
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