Information:
Error:
INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).
- StudyEvent: E1105 Quality of Life Assessment Form
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Protocol Number ECOG
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Patient ID ECOG
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Generic drug form
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
Registration Number
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
Patient Initials
Item
Patient Initials (Last, First)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Data amended
Item
Please mark an 'X' if data have been amended (Please circle amended items in red)
text
C25704 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Data amended date
Item
Date data amended (M D Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Item
On Treatment Report Period (Maintenance 1 cycle = 3 weeks)
text
C25284 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C25214 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
C2045829 (UMLS CUI-1)
C25214 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
CL Item
Cycle 5 (Cycle 5)
CL Item
Cycle 8 (cycle 8)
CL Item
Cycle 24 (Cycle 24)
CL Item
Cycle 40 (Cycle 40)
CL Item
Cycle 56 (Cycle 56)
CL Item
Cycle 72 (Cycle 72)
CL Item
End Of Treatment (End of Treatment)
Item
I have a lack of energy.
integer
C25664 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C3036 (NCI Thesaurus ObjectClass-2)
C3830237 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C3036 (NCI Thesaurus ObjectClass-2)
C3830237 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I have pain.
text
C25664 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C3303 (NCI Thesaurus ObjectClass-2)
C0030193 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C3303 (NCI Thesaurus ObjectClass-2)
C0030193 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I have nausea.
text
C25664 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C3258 (NCI Thesaurus ObjectClass-2)
C0027497 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C3258 (NCI Thesaurus ObjectClass-2)
C0027497 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I have certain areas of my body where I experience significant pain
text
C16960 (NCI Thesaurus ObjectClass)
C41130 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
CL232212 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0520962 (UMLS CUI-1)
C41130 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
CL232212 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0520962 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I have been short of breath.
text
C25664 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C2998 (NCI Thesaurus ObjectClass-2)
C0013404 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C2998 (NCI Thesaurus ObjectClass-2)
C0013404 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I worry that my condition will get worse
text
C16960 (NCI Thesaurus ObjectClass)
C0233481 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C25751 (NCI Thesaurus Property-2)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3641156 (UMLS CUI-1)
C0233481 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C25751 (NCI Thesaurus Property-2)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3641156 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I am content with the quality of my life right now
text
C16960 (NCI Thesaurus ObjectClass)
C17047 (NCI Thesaurus Property)
C20989 (NCI Thesaurus Property-2)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS CUI-1)
C17047 (NCI Thesaurus Property)
C20989 (NCI Thesaurus Property-2)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
Because of my physical condition, I have trouble meeting the needs of my family.
text
C25284 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C3830235 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C25755 (NCI Thesaurus Property)
C3830235 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I am bothered by side effects of treatment.
text
C20989 (NCI Thesaurus ObjectClass)
C27990 (NCI Thesaurus ObjectClass-2)
C25755 (NCI Thesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C2984047 (UMLS CUI-1)
C27990 (NCI Thesaurus ObjectClass-2)
C25755 (NCI Thesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C2984047 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I have numbness or tingling in my hands
text
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0239836 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829780 (UMLS CUI-1)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0239836 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829780 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I have numbness or tingling in my feet
text
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
CL108114 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829781 (UMLS CUI-1)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
CL108114 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3829781 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I feel discomfort in my hands
text
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C32712 (NCI Thesaurus Property-2)
CL047845 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3830164 (UMLS CUI-1)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C32712 (NCI Thesaurus Property-2)
CL047845 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3830164 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)
Item
I feel discomfort in my feet
text
C16960 (NCI Thesaurus ObjectClass)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
CL050515 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3830165 (UMLS CUI-1)
C27961 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
CL050515 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C3830165 (UMLS CUI-1)
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
CL Item
A little bit (2)
C2984078 (UMLS CUI-1)
CL Item
Somewhat (3)
C2984079 (UMLS CUI-1)
CL Item
Quite a bit (4)
C2984080 (UMLS CUI-1)
CL Item
Very much (5)
C2984081 (UMLS CUI-1)