ID

9545

Beschrijving

RTOG-0924 QL: PSQI/GLTEQ Form Androgen-Deprivation Therapy and Radiation Therapy in Treating Patients With Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D869ED1-F271-8812-E040-BB89AD432EA8

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D869ED1-F271-8812-E040-BB89AD432EA8

Trefwoorden

Versies (3)
  1. 20-09-12 20-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

9 januari 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer NCT01368588 Quality of Life - RTOG-0924 QL: PSQI/GLTEQ Form - 3196710v1.0

Engels

INSTRUCTIONS: This page must be completed by the medical staff( nurse, data manager, physician, etc.) Questionnaires for all time points are required even if submission time points deviate from the specified intervals. Only patient death or documented patient refusal will be an acceptable reason for omission of the QOL questionnaires. However, this page must be completed and submitted for every time point on the calendar regardless of whether the QOL questionnaire was completed. Every effort possible should be made to collect the data on time

1 Formulieren  
Unnamed Module 1
Beschrijving

Unnamed Module 1

RTOG Study No.
Beschrijving

Protocol ID RTOG

Datatype

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 #
Beschrijving

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Datatype

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
Beschrijving

Institution Name

Datatype

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.
Beschrijving

Institution Number

Datatype

text

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

Patient Initials

Datatype

text

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

Trial subject ID RTOG

Datatype

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
Beschrijving

Data amended

Datatype

boolean

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

Unamed Module 2

Time point
Beschrijving

AssessmentPeriodType

Datatype

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
Beschrijving

AssessmentPeriodSpecify

Datatype

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
Did the patient complete any items on the questionnaire?
Beschrijving

PatientQuestionnaireCompleteInd-2

Datatype

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 Questionnaire Completed
Beschrijving

QualityofLifeCompleteAssessmentDate

Datatype

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
Beschrijving

Incomplete documentation, reason

Datatype

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
Beschrijving

PatientRefuseIncompleteQuestionnaireSpecify

Datatype

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
Beschrijving

PatientIncompleteQuestionnaireOtherSpecify

Datatype

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
Did the patient require any assistance in completing the questionnaire?
Beschrijving

PatientQuestionnaireAssistanceInd

Datatype

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
Extent of assistance given
Beschrijving

PatientQuestionnaireAssistanceType

Datatype

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
Beschrijving

PatientQuestionnaireAssistanceCombinedSpecify

Datatype

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
Beschrijving

PatientQuestionnaireAssistanceOtherSpecify

Datatype

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
Specify the person who assisted the patient
Beschrijving

PatientQuestionnaireAssistancePersonCategory

Datatype

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
Specify method of completion
Beschrijving

PatientQuestionnaireCompleteMethodofCollectionType

Datatype

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
Comments
Beschrijving

Research Comments

Datatype

text

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

Responsible Person Signature

Datatype

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
Beschrijving

Form Completion Date

Datatype

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
Beschrijving

Exercise

Times per week (Mild exercise - that is, minimal effort exercise that did not make you perspire, such as easy walking, yoga, bowling, lawn bowling, shuffleboard, or golf)
Beschrijving

QualityofLifeMildExercisePerformedAssessmentWeekFrequency

Datatype

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 (Mild exercise - that is, minimal effort exercise that did not make you perspire, such as easy walking, yoga, bowling, lawn bowling, shuffleboard, or golf mins.)
Beschrijving

QualityofLifeMildExercisePerformedAssessmentDuration

Datatype

float

Maateenheden
  • 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 (Moderate exercise - that is, exercise that is not exhausting and which made you perspire lightly, such as fast walking, tennis, easy bicycling, easy swimming, or popular and folk dancing)
Beschrijving

QualityofLifeModerateExercisePerformedAssessmentWeekFrequency

Datatype

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 (Moderate exercise - that is, exercise that is not exhausting and which made you perspire lightly, such as fast walking, tennis, easy bicycling, easy swimming, or popular and folk dancing mins.)
Beschrijving

QualityofLifeModerateExercisePerformedAssessmentDuration

Datatype

float

Maateenheden
  • 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 (Strenuous exercise - that is, exercise that made your heart beat rapidly and made you sweat, such as running, aerobics classes, cross country skiing, vigorous swimming, or vigorous bicycling)
Beschrijving

QualityofLifeHighExercisePerformedAssessmentWeekFrequency

Datatype

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 (Strenuous exercise - that is, exercise that made your heart beat rapidly and made you sweat, such as running, aerobics classes, cross country skiing, vigorous swimming, or vigorous bicycling mins.)
Beschrijving

QualityofLifeHighExercisePerformedAssessmentDuration

Datatype

float

Maateenheden
  • 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
Beschrijving

QualityofLifeMuscleWeaknessAssessmentScore

Datatype

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 month, how would you rate your sleep quality overall
Beschrijving

QualityofLifeSleepQualityAssessmentScore

Datatype

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
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INSTRUCTIONS: This page must be completed by the medical staff( nurse, data manager, physician, etc.) Questionnaires for all time points are required even if submission time points deviate from the specified intervals. Only patient death or documented patient refusal will be an acceptable reason for omission of the QOL questionnaires. However, this page must be completed and submitted for every time point on the calendar regardless of whether the QOL questionnaire was completed. Every effort possible should be made to collect the data on time

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
Baseline (baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
CL Item
Last Week Of Radiation Therapy (Last week of RT)
CL Item
3 Months After Rt (3 months after 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)
PatientQuestionnaireCompleteInd-2
Item
Did the patient complete any items on the questionnaire?
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 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 available in patient's language)
CL Item
Other Reason (Other reason)
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
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.5
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
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.6
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)
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)
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)
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.8
Code List
Specify method of completion
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)
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 (Mild exercise - that is, minimal effort exercise that did not make you perspire, such as easy walking, yoga, bowling, lawn bowling, shuffleboard, or golf)
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 (Mild exercise - that is, minimal effort exercise that did not make you perspire, such as easy walking, yoga, bowling, lawn bowling, shuffleboard, or golf mins.)
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 (Moderate exercise - that is, exercise that is not exhausting and which made you perspire lightly, such as fast walking, tennis, easy bicycling, easy swimming, or popular and folk dancing)
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 (Moderate exercise - that is, exercise that is not exhausting and which made you perspire lightly, such as fast walking, tennis, easy bicycling, easy swimming, or popular and folk dancing mins.)
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 (Strenuous exercise - that is, exercise that made your heart beat rapidly and made you sweat, such as running, aerobics classes, cross country skiing, vigorous swimming, or vigorous bicycling)
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 (Strenuous exercise - that is, exercise that made your heart beat rapidly and made you sweat, such as running, aerobics classes, cross country skiing, vigorous swimming, or vigorous bicycling mins.)
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)
CL.9
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 month, 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)
CL.10
Code List
During the past month, 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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