This form should be completed every 3 months while the patient is receiving protocol therapy, and every 6 months after the last dose of protocol therapy, for up to one year.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Patient Initials
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
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)
AffiliatedInstitutionName
Item
Affiliate Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C0018704 (UMLS 2011AA ValueDomain-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25413 (NCI Thesaurus ObjectClass-2)
C1510826 (UMLS 2011AA ObjectClass-2)
Person Completing Form Last Name
Item
Person Completing Form Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form First Name
Item
Person Completing Form First Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1443235 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form Phone
Item
Person Completing Form Phone
text
C25337 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI-2)
C25657 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)
Data amended
Item
Are data amended? (check box if yes, and circle amended items)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Blood pressure assessment
Item
Time point of this assessment
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25257 (NCI Thesaurus Property)
C0205390 (UMLS 2011AA Property)
CL.2
Code List
Time point of this assessment
CL Item
3 (3 months)
CL Item
6 (6 months)
CL Item
9 (9 months)
CL Item
12 (12 months)
CL Item
6 Months After Protocol Therapy (6 months after protocol therapy)
CL Item
12 Months After Protocol Therapy (12 months after protocol therapy)
CL Item
Mfolfox6 +/- Bevacizumab (mFOLFOX6 +/- bevacizumab)
CL Item
Bevacizumab Alone (Bevacizumab alone)
CL Item
Post-therapy (Post-therapy)
C54735 (NCI Thesaurus)
C1882428 (UMLS 2011AA)
BloodPressure,Systolic
Item
Blood Pressure Systolic (mm Hg)
float
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Bloodpressure,Diastolic
Item
Blood Pressure Diastolic (mm Hg)
text
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25299 (NCI Thesaurus ObjectClass)
C0428883 (UMLS 2011AA ObjectClass)
Assessment Date
Item
Date of Measurement (Month Day Year)
date
C25164 (NCI Thesaurus ValueDomain)
C2985720 (UMLS CUI-1)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C38000 (NCI Thesaurus Property)
AntihypertensiveAgentAdministeredInd-2
Item
Does the patient have hypertension requiring medication?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C270 (NCI Thesaurus ObjectClass)
C0003364 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
AntihypertensiveAgentModificationInd-2
Item
Has there been an addition of a new anti-hypertensive agent or a modification of an existing agent since the last HT form?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C270 (NCI Thesaurus ObjectClass)
C0003364 (UMLS 2011AA ObjectClass)
C25572 (NCI Thesaurus Property)
Item
Specify the action(s) taken (select all that apply:)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3117 (NCI Thesaurus ObjectClass)
C0020538 (UMLS 2011AA ObjectClass)
C25404 (NCI Thesaurus Property)
C0441472 (UMLS 2011AA Property)
CL.5
Code List
Specify the action(s) taken (select all that apply:)
CL Item
Increase In Dose Of Existing Medication (Increase in dose of existing medication)
CL Item
Decrease In Dose Of Existing Medication (Decrease in dose of existing medication)
CL Item
Addition Of New Medication (Addition of new medication)
CL Item
Discontinuation Of Existing Medication (Discontinuation of existing medication)
Item
Reason action(s) taken:
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3117 (NCI Thesaurus ObjectClass)
C0020538 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.6
Code List
Reason action(s) taken:
CL Item
Blood Pressure Poorly Controlled On Previous Regimen (Blood pressure poorly controlled on previous regimen)
CL Item
Previous Dose/medication No Longer Required (Previous dose/medication no longer required)
CL Item
Toxicity/side Effects (Toxicity/side effects)
Agent
Item
Generic Name (List the generic names, dose, unit and frequency of a any new medications the patient is taking since the last HT form, and b any medications for which there was a change in dose or frequency since the last HT form.)
text
C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
RadiationTherapyDose
Item
Dose
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
Item
Unit
text
CL.7
Code List
Unit
CL Item
Gram (g)
C0439208 (NCI Metathesaurus)
CL Item
Milligram (mg)
C28253 (NCI Thesaurus)
C0439210 (UMLS 2011AA)
Frequency
Item
Frequency
text
C25515 (NCI Thesaurus ObjectClass)
C0439603 (UMLS 2011AA ObjectClass)
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