ID

9552

Description

RTOG 1115 FA: Phase III RT + Standard ADT vs RT + Enhanced ADT + TAK-700 Expanded Prostate Cancer Index Composite (EPIC) Form Hormone Therapy, Radiation Therapy, and Steroid 17alpha-monooxygenase TAK-700 in Treating Patients With High-Risk Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AE8E7874-4C98-11A5-E040-BB89AD43766D

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AE8E7874-4C98-11A5-E040-BB89AD43766D

Keywords

Versions (4)
  1. 9/19/12 9/19/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 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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NCT01546987 Quality of Life - RTOG 1115 FA: Phase III RT + Standard ADT vs RT + Enhanced ADT + TAK-700 Expanded Prostate Cancer Index Composite (EPIC) Form - 3288539v1.0

English

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 forms  
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
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
Did the patient complete any items on the questionnaire?
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 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
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
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
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
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
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 Completed
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
Epic: The Expanded Prostate Cancer Index Composite
Description

Epic: The Expanded Prostate Cancer Index Composite

Today's date (please enter date when survey completed Month Day Year)
Description

CompleteQuestionnaireDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25250
UMLS 2011AA ObjectClass
C0205197
NCI Thesaurus ObjectClass-2
C17048
UMLS 2011AA ObjectClass-2
C0034394
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25250
UMLS 2011AA ValueDomain-2
C0205197
Name (optional)
Description

Patient Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1299487
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
Date of Birth (optional Month Day Year)
Description

PersonBirthDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25155
UMLS 2011AA Property
C0005615
Quality Of Life Module
Description

Quality Of Life Module

Over the past 4 weeks how often have you leaked urine (Circle one number)
Description

ProstateQualityofLifeUrinaryLeakageSymptomScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25711
UMLS 2011AA Property
C1524119
NCI Thesaurus Property-2
C4876
UMLS 2011AA Property-2
C1457887
NCI Thesaurus Property-3
C40416
UMLS 2011AA Property-3
C0015376
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the past 4 weeks, how often have you urinated blood (Circle one number)
Description

ProstateQualityofLifeHematuriaProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3090
UMLS 2011AA Property
C0018965
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Over the past 4 weeks, how often have you had pain or burning with urination (Circle one number)
Description

ProstateQualityofLifeUrinePainProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C13283
UMLS 2011AA Property-2
C0042036
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Which of the following best describes your urinary control during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeUrinaryControlSymptomScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25711
UMLS 2011AA Property
C1524119
NCI Thesaurus Property-2
C4876
UMLS 2011AA Property-2
C1457887
NCI Thesaurus Property-3
C61299
UMLS 2011AA Property-3
C2587213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
Description

ProstateQualityofLifeAdultUndergarmentUseScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C17600
UMLS 2011AA Property
C0001675
NCI Thesaurus Property-2
C25340
UMLS 2011AA Property-2
C0457083
NCI Metathesaurus Property
C0453880
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Circle one number on each line)
Description

ProstateQualityofLifeUrineLeakageProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C13283
UMLS 2011AA Property
C0042036
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C40416
UMLS 2011AA Property-3
C0015376
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Pain or burning on urination
Description

ProstateQualityofLifeUrinePainProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C13283
UMLS 2011AA Property-2
C0042036
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Bleeding with urination
Description

ProstateQualityofLifeHematuriaProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3090
UMLS 2011AA Property
C0018965
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Weak urine stream or incomplete emptying
Description

ProstateQualityofLifeIncompleteUrinationProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C25744
UMLS 2011AA Property-3
C0042034
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Waking up to urinate
Description

ProstateQualityofLifeAwakeningUrinationProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property-2
C25744
UMLS 2011AA Property-2
C0042034
NCI Thesaurus Property-3
C64921
UMLS 2011AA Property-3
C1883476
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Need to urinate frequently during the day
Description

ProstateQualityofLifeUrinaryFrequencyProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C26906
UMLS 2011AA Property
C0677481
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeOverallUrinaryProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property-2
C25711
UMLS 2011AA Property-2
C1524119
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Quality Of Life Module
Description

Quality Of Life Module

How often have you had rectal urgency (felt like I had to pass stool, but did not) during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeDefecationUrgencyProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property-2
C62788
UMLS 2011AA Property-2
C0426636
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How often have you had uncontrolled leakage of stool or feces (Circle one number)
Description

ProstateQualityofLifeAnalIncontinenceProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C43362
UMLS 2011AA Property
C0003461
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Metathesaurus Property
C0021167
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How often have you had stools (bowel movements) that were loose or liquid (no form, watery, mushy) during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeDiarrheaProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C2987
UMLS 2011AA Property
C0011991
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How often have you had bloody stools during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeBloodFecesProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C12434
UMLS 2011AA Property
C0229664
NCI Thesaurus Property-2
C13234
UMLS 2011AA Property-2
C0015733
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How often have your bowel movements been painful during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeDefecationPainProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C62787
UMLS 2011AA Property-3
C0011135
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How many bowel movements have you had on a typical day during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeDefecationFrequencyProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property-2
C25515
UMLS 2011AA Property-2
C0439603
NCI Thesaurus Property-3
C62787
UMLS 2011AA Property-3
C0011135
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How often have you had crampy pain in your abdomen, pelvis or rectum during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeAbdominalPainProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C25342
UMLS 2011AA Property-2
C0000726
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Circle one number on each line)
Description

ProstateQualityofLifeDefecationUrgencyProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property-2
C62788
UMLS 2011AA Property-2
C0426636
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Increased frequency of bowel movements
Description

ProstateQualityofLifeDefecationFrequencyProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property-2
C25515
UMLS 2011AA Property-2
C0439603
NCI Thesaurus Property-3
C62787
UMLS 2011AA Property-3
C0011135
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Watery bowel movements
Description

ProstateQualityofLifeDiarrheaProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C2987
UMLS 2011AA Property
C0011991
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Losing control of your stools
Description

ProstateQualityofLifeAnalIncontinenceProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C43362
UMLS 2011AA Property
C0003461
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Metathesaurus Property
C0021167
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Bloody stools
Description

ProstateQualityofLifeBloodFecesProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C12434
UMLS 2011AA Property
C0229664
NCI Thesaurus Property-2
C13234
UMLS 2011AA Property-2
C0015733
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Abdominal/pelvic/rectal pain
Description

ProstateQualityofLifeAbdominalPainProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property-2
C25342
UMLS 2011AA Property-2
C0000726
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeOverallBowelProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property-2
C12736
UMLS 2011AA Property-2
C0021853
NCI Thesaurus Property-3
C28020
UMLS 2011AA Property-3
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Quality Of Life Module
Description

Quality Of Life Module

Your level of sexual desire (How would you rate each of the following during the last 4 weeks? Circle one number on each line)
Description

SexBehaviorQualityofLifeLibidoOccurrenceAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C17127
UMLS 2011AA ObjectClass-2
C0036864
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property-3
C37986
UMLS 2011AA Property-2
C0023618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your ability to have an erection
Description

ProstateQualityofLifeErectionFunctionScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property-2
C25740
UMLS 2011AA Property-2
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your ability to reach orgasm (climax)
Description

ProstateQualityofLifeEjaculationFunctionScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property-2
C16531
UMLS 2011AA Property-2
C0013746
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How would you describe the usual QUALITY of your erections during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeErectionQualityScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25283
UMLS 2011AA Property
C0332306
NCI Thesaurus Property-2
C25740
UMLS 2011AA Property-2
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How would you describe the FREQUENCY of your erections during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeErectionFrequencyScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property-2
C25740
UMLS 2011AA Property-2
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How often have you awakened in the morning or night with an erection during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeErectionUponAwakeningFunctionScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property-2
C64921
UMLS 2011AA Property-2
C1883476
NCI Thesaurus Property-3
C25740
UMLS 2011AA Property-3
C0030847
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
During the last 4 weeks, how often did you have any sexual activity (Circle one number)
Description

SexBehaviorQualityofLifeLibidoAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C17127
UMLS 2011AA ObjectClass-2
C0036864
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C37986
UMLS 2011AA Property
C0023618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
During the last 4 weeks, how often did you have sexual intercourse (Circle one number)
Description

Sexual activity

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS CUI-1
C0036864
NCI Thesaurus ObjectClass-2
C17127
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C25275
NCI Thesaurus Property-3
C72881
NCI Thesaurus ValueDomain
C25664
Overall, how would you rate your ability to function sexually during the last 4 weeks
Description

ProstateQualityofLifeOverallLibidoFunctionScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property-2
C25518
UMLS 2011AA Property-2
C0542341
NCI Thesaurus Property-3
C37986
UMLS 2011AA Property-3
C0023618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your level of sexual desire (How big a problem during the last 4 weeks, if any, has each of the following been for you? Circle one number on each line)
Description

SexBehaviorQualityofLifeLibidoOccurrenceAssessmentType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C17127
UMLS 2011AA ObjectClass-2
C0036864
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property-3
C37986
UMLS 2011AA Property-2
C0023618
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Your ability to have an erection
Description

ProstateQualityofLifeErectionFunctionType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property-2
C25740
UMLS 2011AA Property-2
C0030847
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Your ability to reach an orgasm
Description

ProstateQualityofLifeEjaculationFunctionType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus Property-2
C16531
UMLS 2011AA Property-2
C0013746
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
Description

ProstateQualityofLifeOverallLibidoProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25605
UMLS 2011AA Property
C1561607
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C37986
UMLS 2011AA Property-3
C0023618
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Quality Of Life Module
Description

Quality Of Life Module

Over the last 4 weeks, how often have you experienced hot flashes (Circle one number)
Description

ProstateQualityofLifeHotFlashesProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3109
UMLS 2011AA Property
C0600142
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How often have you had breast tenderness during the last 4 weeks (Circle one number)
Description

ProstateQualityofLifeBreastSwellingProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C3399
UMLS 2011AA Property-3
C0038999
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
During the last 4 weeks, how often have you felt depressed (Circle one number)
Description

ProstateQualityofLifeDepressionProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C2982
UMLS 2011AA Property
C0011570
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
During the last 4 weeks, how often have you felt a lack of energy (Circle one number)
Description

ProstateQualityofLifeFatigueProblemScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3036
UMLS 2011AA Property
C0015672
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
How much change in your weight have you experienced during the last 4 weeks, if any (Circle one number)
Description

ProstateQualityofLifeWeightProblemStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25208
UMLS 2011AA Property
C0043100
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Circle one number on each line)
Description

ProstateQualityofLifeHotFlashesProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3109
UMLS 2011AA Property
C0600142
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Breast tenderness/enlargement
Description

ProstateQualityofLifeBreastSwellingProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus Property-3
C3399
UMLS 2011AA Property-3
C0038999
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Loss of Body Hair
Description

PatientSelf-ReportAlopeciaAssessmentType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C21089
UMLS 2011AA ObjectClass
C0681906
NCI Thesaurus Property-2
C50575
UMLS 2011AA Property
C0002170
Feeling depressed
Description

ProstateQualityofLifeDepressionProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C2982
UMLS 2011AA Property
C0011570
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Lack of energy
Description

ProstateQualityofLifeFatigueProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C3036
UMLS 2011AA Property
C0015672
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Change in body weight
Description

ProstateQualityofLifeWeightProblemType

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C12410
UMLS 2011AA ObjectClass-2
C0033572
NCI Thesaurus Property
C25208
UMLS 2011AA Property
C0043100
NCI Thesaurus Property-2
C28020
UMLS 2011AA Property-2
C0033213
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Overall Satisfaction
Description

Overall Satisfaction

Overall, how satisfied are you with the treatment you received for your prostate cancer (Circle one number)
Description

PatientSatisfactionTherapyQualityofLifeAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C62185
UMLS 2011AA ObjectClass-2
C0242428
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C15368
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
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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 forms
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
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
Pretreatment (Pretreatment)
CL Item
Last Week Of Radiation Therapy (Last week of RT)
CL Item
12 Months From Start Of Treatment (12 months from start of treatment)
CL Item
30 Months From Start Of Treatment (30 months from start of treatment)
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)
Date Form Completed
Item
Date Form Completed
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Item Group
Epic: The Expanded Prostate Cancer Index Composite
CompleteQuestionnaireDate
Item
Today's date (please enter date when survey completed Month Day Year)
date
C25250 (NCI Thesaurus ObjectClass)
C0205197 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus ObjectClass-2)
C0034394 (UMLS 2011AA ObjectClass-2)
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25250 (NCI Thesaurus ValueDomain-2)
C0205197 (UMLS 2011AA ValueDomain-2)
Patient Name
Item
Name (optional)
text
C25191 (NCI Thesaurus ValueDomain)
C1299487 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
PersonBirthDate
Item
Date of Birth (optional Month Day Year)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25155 (NCI Thesaurus Property)
C0005615 (UMLS 2011AA Property)
Item Group
Quality Of Life Module
Item
Over the past 4 weeks how often have you leaked urine (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25711 (NCI Thesaurus Property)
C1524119 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property-2)
C1457887 (UMLS 2011AA Property-2)
C40416 (NCI Thesaurus Property-3)
C0015376 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.9
Code List
Over the past 4 weeks how often have you leaked urine (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
Item
Over the past 4 weeks, how often have you urinated blood (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3090 (NCI Thesaurus Property)
C0018965 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.10
Code List
Over the past 4 weeks, how often have you urinated blood (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
Over the past 4 weeks, how often have you had pain or burning with urination (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C13283 (NCI Thesaurus Property-2)
C0042036 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.11
Code List
Over the past 4 weeks, how often have you had pain or burning with urination (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
Which of the following best describes your urinary control during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25711 (NCI Thesaurus Property)
C1524119 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property-2)
C1457887 (UMLS 2011AA Property-2)
C61299 (NCI Thesaurus Property-3)
C2587213 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.12
Code List
Which of the following best describes your urinary control during the last 4 weeks (Circle one number)
CL Item
No Urinary Control (No urinary control whatsoever)
CL Item
Frequent Dribbling (Frequent dribbling)
CL Item
Occasional Dribbling (Occasional dribbling)
CL Item
Normal Urinary Control (Total control)
Item
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C17600 (NCI Thesaurus Property)
C0001675 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
C0453880 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.13
Code List
How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
C41132 (NCI Thesaurus-3)
C0549184 (UMLS 2011AA-4)
CL Item
1 Per Day (1 pad per day)
CL Item
2 Per Day (2 pads per day)
CL Item
3+ Per Day (3 or more pads per day)
Item
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Circle one number on each line)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C13283 (NCI Thesaurus Property)
C0042036 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C40416 (NCI Thesaurus Property-3)
C0015376 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.14
Code List
Dripping or leaking urine (How big a problem, if any, has each of the following been for you during the last 4 weeks? Circle one number on each line)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Pain or burning on urination
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C13283 (NCI Thesaurus Property-2)
C0042036 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.15
Code List
Pain or burning on urination
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Bleeding with urination
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3090 (NCI Thesaurus Property)
C0018965 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.16
Code List
Bleeding with urination
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Weak urine stream or incomplete emptying
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25744 (NCI Thesaurus Property-3)
C0042034 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.17
Code List
Weak urine stream or incomplete emptying
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Waking up to urinate
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25744 (NCI Thesaurus Property-2)
C0042034 (UMLS 2011AA Property-2)
C64921 (NCI Thesaurus Property-3)
C1883476 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.18
Code List
Waking up to urinate
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Need to urinate frequently during the day
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C26906 (NCI Thesaurus Property)
C0677481 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.19
Code List
Need to urinate frequently during the day
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25711 (NCI Thesaurus Property-2)
C1524119 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.20
Code List
Overall, how big a problem has your urinary function been for you during the last 4 weeks (Circle one number)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item Group
Quality Of Life Module
Item
How often have you had rectal urgency (felt like I had to pass stool, but did not) during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C62788 (NCI Thesaurus Property-2)
C0426636 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.21
Code List
How often have you had rectal urgency (felt like I had to pass stool, but did not) during the last 4 weeks (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
How often have you had uncontrolled leakage of stool or feces (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C43362 (NCI Thesaurus Property)
C0003461 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C0021167 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.22
Code List
How often have you had uncontrolled leakage of stool or feces (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
How often have you had stools (bowel movements) that were loose or liquid (no form, watery, mushy) during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C2987 (NCI Thesaurus Property)
C0011991 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.23
Code List
How often have you had stools (bowel movements) that were loose or liquid (no form, watery, mushy) during the last 4 weeks (Circle one number)
CL Item
Never (Never)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Rarely (Rarely)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
CL Item
About Half The Time (About half the time)
CL Item
Usually (Usually)
CL Item
Always (Always)
Item
How often have you had bloody stools during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C12434 (NCI Thesaurus Property)
C0229664 (UMLS 2011AA Property)
C13234 (NCI Thesaurus Property-2)
C0015733 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.24
Code List
How often have you had bloody stools during the last 4 weeks (Circle one number)
CL Item
Never (Never)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Rarely (Rarely)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
CL Item
About Half The Time (About half the time)
CL Item
Usually (Usually)
CL Item
Always (Always)
Item
How often have your bowel movements been painful during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C62787 (NCI Thesaurus Property-3)
C0011135 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.25
Code List
How often have your bowel movements been painful during the last 4 weeks (Circle one number)
CL Item
Never (Never)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Rarely (Rarely)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
CL Item
About Half The Time (About half the time)
CL Item
Usually (Usually)
CL Item
Always (Always)
Item
How many bowel movements have you had on a typical day during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25515 (NCI Thesaurus Property-2)
C0439603 (UMLS 2011AA Property-2)
C62787 (NCI Thesaurus Property-3)
C0011135 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.26
Code List
How many bowel movements have you had on a typical day during the last 4 weeks (Circle one number)
CL Item
Two Or Less (Two or less)
CL Item
Three To Four (Three to four)
CL Item
Five Or More (Five or more)
Item
How often have you had crampy pain in your abdomen, pelvis or rectum during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25342 (NCI Thesaurus Property-2)
C0000726 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.27
Code List
How often have you had crampy pain in your abdomen, pelvis or rectum during the last 4 weeks (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Circle one number on each line)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C62788 (NCI Thesaurus Property-2)
C0426636 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.28
Code List
Urgency to have a bowel movement (How big a problem, if any, has each of the following been for you? Circle one number on each line)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Increased frequency of bowel movements
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C25515 (NCI Thesaurus Property-2)
C0439603 (UMLS 2011AA Property-2)
C62787 (NCI Thesaurus Property-3)
C0011135 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.29
Code List
Increased frequency of bowel movements
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Watery bowel movements
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C2987 (NCI Thesaurus Property)
C0011991 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.30
Code List
Watery bowel movements
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Severe Problem (Big problem)
Item
Losing control of your stools
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C43362 (NCI Thesaurus Property)
C0003461 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C0021167 (NCI Metathesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.31
Code List
Losing control of your stools
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Bloody stools
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C12434 (NCI Thesaurus Property)
C0229664 (UMLS 2011AA Property)
C13234 (NCI Thesaurus Property-2)
C0015733 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.32
Code List
Bloody stools
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Abdominal/pelvic/rectal pain
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25342 (NCI Thesaurus Property-2)
C0000726 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.33
Code List
Abdominal/pelvic/rectal pain
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C12736 (NCI Thesaurus Property-2)
C0021853 (UMLS 2011AA Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.34
Code List
Overall, how big a problem have your bowel habits been for you during the last 4 weeks (Circle one number)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item Group
Quality Of Life Module
Item
Your level of sexual desire (How would you rate each of the following during the last 4 weeks? Circle one number on each line)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass-2)
C0036864 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property)
C37986 (NCI Thesaurus Property-3)
C0023618 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.35
Code List
Your level of sexual desire (How would you rate each of the following during the last 4 weeks? Circle one number on each line)
CL Item
Very Poor To None (Very Poor to None)
CL Item
Poor (Poor)
C77959 (NCI Thesaurus)
C2700379 (UMLS 2011AA)
CL Item
Fair (Fair)
CL Item
Good (Good)
CL Item
Very Good (Very Good)
Item
Your ability to have an erection
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property-2)
C0030847 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.36
Code List
Your ability to have an erection
CL Item
None (Very poor to None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
Your ability to reach orgasm (climax)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C16531 (NCI Thesaurus Property-2)
C0013746 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.37
Code List
Your ability to reach orgasm (climax)
CL Item
None (Very poor to None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
How would you describe the usual QUALITY of your erections during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25283 (NCI Thesaurus Property)
C0332306 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property-2)
C0030847 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.38
Code List
How would you describe the usual QUALITY of your erections during the last 4 weeks (Circle one number)
CL Item
None (None at all)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Not Firm Enough For Any Sexual Activity (Not firm enough for any sexual activity)
CL Item
Firm Enough For Masturbation And Foreplay Only (Firm enough for masturbation and foreplay only)
CL Item
Firm Enough For Intercourse (Firm enough for intercourse)
Item
How would you describe the FREQUENCY of your erections during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property-2)
C0030847 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.39
Code List
How would you describe the FREQUENCY of your erections during the last 4 weeks (Circle one number)
CL Item
Never (I NEVER had an erection when I wanted one)
CL Item
Less Than Half (I had an erection LESS THAN HALF the time I wanted one)
CL Item
About Half (approximately 50%) (I had an erection ABOUT HALF the time I wanted one)
CL Item
More Than Half (I had an erection MORE THAN HALF the time I wanted one)
CL Item
Normal (I had an erection WHENEVER I wanted one)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
Item
How often have you awakened in the morning or night with an erection during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C64921 (NCI Thesaurus Property-2)
C1883476 (UMLS 2011AA Property-2)
C25740 (NCI Thesaurus Property-3)
C0030847 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.40
Code List
How often have you awakened in the morning or night with an erection during the last 4 weeks (Circle one number)
CL Item
Never (Never)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Less Than Once A Week (Less than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Several Times A Week (Several times a week)
CL Item
Daily (Daily)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
Item
During the last 4 weeks, how often did you have any sexual activity (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass-2)
C0036864 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C37986 (NCI Thesaurus Property-2)
C0023618 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.41
Code List
During the last 4 weeks, how often did you have any sexual activity (Circle one number)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Less Than Once A Week (Less than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Several Times A Week (Several times a week)
CL Item
Daily (Daily)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
Item
During the last 4 weeks, how often did you have sexual intercourse (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0036864 (UMLS CUI-1)
C17127 (NCI Thesaurus ObjectClass-2)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C72881 (NCI Thesaurus Property-3)
C25664 (NCI Thesaurus ValueDomain)
CL.42
Code List
During the last 4 weeks, how often did you have sexual intercourse (Circle one number)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
Less Than Once A Week (Less than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Several Times A Week (Several times a week)
CL Item
Daily (Daily)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
Item
Overall, how would you rate your ability to function sexually during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25518 (NCI Thesaurus Property-2)
C0542341 (UMLS 2011AA Property-2)
C37986 (NCI Thesaurus Property-3)
C0023618 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.43
Code List
Overall, how would you rate your ability to function sexually during the last 4 weeks
CL Item
Very Poor (Very poor)
CL Item
Poor (Poor)
CL Item
Fair (Fair)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Very Good (Very Good)
Item
Your level of sexual desire (How big a problem during the last 4 weeks, if any, has each of the following been for you? Circle one number on each line)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass-2)
C0036864 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property)
C37986 (NCI Thesaurus Property-3)
C0023618 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.44
Code List
Your level of sexual desire (How big a problem during the last 4 weeks, if any, has each of the following been for you? Circle one number on each line)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Your ability to have an erection
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property-2)
C0030847 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.45
Code List
Your ability to have an erection
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Your ability to reach an orgasm
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C16531 (NCI Thesaurus Property-2)
C0013746 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.46
Code List
Your ability to reach an orgasm
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C37986 (NCI Thesaurus Property-3)
C0023618 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.47
Code List
Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item Group
Quality Of Life Module
Item
Over the last 4 weeks, how often have you experienced hot flashes (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3109 (NCI Thesaurus Property)
C0600142 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.48
Code List
Over the last 4 weeks, how often have you experienced hot flashes (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
How often have you had breast tenderness during the last 4 weeks (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C3399 (NCI Thesaurus Property-3)
C0038999 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.49
Code List
How often have you had breast tenderness during the last 4 weeks (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
During the last 4 weeks, how often have you felt depressed (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C2982 (NCI Thesaurus Property)
C0011570 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.50
Code List
During the last 4 weeks, how often have you felt depressed (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
During the last 4 weeks, how often have you felt a lack of energy (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3036 (NCI Thesaurus Property)
C0015672 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.51
Code List
During the last 4 weeks, how often have you felt a lack of energy (Circle one number)
CL Item
More Than Once A Day (More than once a day)
CL Item
Once A Day (About once a day)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
More Than Once A Week (More than once a week)
CL Item
About Once A Week (About once a week)
CL Item
Rarely (Rarely or never)
C73116 (NCI Thesaurus)
C0522498 (UMLS 2011AA)
C73116 (NCI Thesaurus-3)
C0522498 (UMLS 2011AA-4)
Item
How much change in your weight have you experienced during the last 4 weeks, if any (Circle one number)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25208 (NCI Thesaurus Property)
C0043100 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.52
Code List
How much change in your weight have you experienced during the last 4 weeks, if any (Circle one number)
CL Item
Gained 10 Pounds Or More (Gained 10 pounds or more)
CL Item
Gained Less Than 10 Pounds (Gained less than 10 pounds)
CL Item
No Change In Weight (No change in weight)
CL Item
Lost Less Than 10 Pounds (Lost less than 10 pounds)
CL Item
Lost 10 Pounds Or More (Lost 10 pounds or more)
Item
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Circle one number on each line)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3109 (NCI Thesaurus Property)
C0600142 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.53
Code List
Hot flashes (How big a problem during the last 4 weeks, if any, has each of the following been for you? Circle one number on each line)
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Breast tenderness/enlargement
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C3399 (NCI Thesaurus Property-3)
C0038999 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.54
Code List
Breast tenderness/enlargement
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Loss of Body Hair
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C21089 (NCI Thesaurus ObjectClass)
C0681906 (UMLS 2011AA ObjectClass)
C50575 (NCI Thesaurus Property-2)
C0002170 (UMLS 2011AA Property)
CL.55
Code List
Loss of Body Hair
CL Item
No Problem (No problem)
CL Item
Very Small Problem (Very small problem)
CL Item
Small Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Big Problem (Big problem)
Item
Feeling depressed
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C2982 (NCI Thesaurus Property)
C0011570 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.56
Code List
Feeling depressed
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Lack of energy
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C3036 (NCI Thesaurus Property)
C0015672 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.57
Code List
Lack of energy
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item
Change in body weight
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12410 (NCI Thesaurus ObjectClass-2)
C0033572 (UMLS 2011AA ObjectClass-2)
C25208 (NCI Thesaurus Property)
C0043100 (UMLS 2011AA Property)
C28020 (NCI Thesaurus Property-2)
C0033213 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.58
Code List
Change in body weight
CL Item
No Problem (No problem)
CL Item
Mild Problem (Very small problem)
CL Item
Mild To Moderate Problem (Small problem)
CL Item
Moderate Problem (Moderate problem)
CL Item
Severe Problem (Big problem)
Item Group
Overall Satisfaction
Item
Overall, how satisfied are you with the treatment you received for your prostate cancer (Circle one number)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C62185 (NCI Thesaurus ObjectClass-2)
C0242428 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C15368 (NCI Thesaurus Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.59
Code List
Overall, how satisfied are you with the treatment you received for your prostate cancer (Circle one number)
CL Item
Extremely Dissatisfied (Extremely dissatisfied)
CL Item
Dissatisfied (Dissatisfied)
CL Item
Uncertain (Uncertain)
C47944 (NCI Thesaurus)
C0087130 (UMLS 2011AA)
CL Item
Satisfied (Satisfied)
CL Item
Extremely Satisfied (Extremely satisfied)
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