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1 forms
  1. StudyEvent: Concomitant Medication Form, GOG-0212, Form CMED
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Form Completion Date
Item
Date form originally completed (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Amendment date
Item
Date form amended (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C0680532 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Person Amending Form
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1547383 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials (First, Middle, Last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient Study ID
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-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)
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)
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)
Additional Form Page Number
Item
Page Number (of)
text
C19464 (NCI Thesaurus ObjectClass)
C1706499 (UMLS CUI-1)
C25406 (NCI Thesaurus ObjectClass-2)
C1704732 (UMLS CUI-2)
C25695 (NCI Thesaurus Property)
C0237753 (UMLS CUI-3)
C25337 (NCI Thesaurus ValueDomain)
C42783 (NCI Thesaurus ValueDomain-2)
Item Group
Medication Information
ConcomitantMedicationReceivedInd-2
Item
Did patient receive concomitant medications while on protocol therapy?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
Concomitant Medication
Item
Concomitant Medication
text
C25704 (NCI Thesaurus ValueDomain)
C2347852 (UMLS CUI-1)
C459 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C25730 (NCI Thesaurus ObjectClass-2)
Item
Units
text
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS CUI-1)
C25730 (NCI Thesaurus Property)
C1519795 (UMLS CUI-2)
C25409 (NCI Thesaurus Property-2)
C25709 (NCI Thesaurus ValueDomain)
CL.2
Code List
Units
CL Item
Capsules (Capsules)
CL Item
Drops (Drops)
C69442 (NCI Thesaurus)
C2347093 (UMLS 2011AA)
CL Item
Gram (Gram)
C48155 (NCI Thesaurus)
C0439208 (UMLS 2011AA)
CL Item
Microgram (Microgram)
CL Item
Microliter (Microliter)
C48153 (NCI Thesaurus)
C0439243 (UMLS 2011AA)
CL Item
Milligram (Milligram)
C28253 (NCI Thesaurus)
C0439210 (UMLS 2011AA)
CL Item
Milliliter (Milliliter)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
CL Item
Not Specified (Not specified)
CL Item
Ounce (Ounce)
C48519 (NCI Thesaurus)
C0439218 (UMLS 2011AA)
CL Item
Puffer (Puffer)
CL Item
Spray (Spray)
CL Item
Suppository (Suppository)
CL Item
Tablespoon (Tablespoon)
CL Item
Teaspoon (Teaspoon)
ConcomitantMedicationAdministeredDose
Item
Concomitant Medication Administered Dose
float
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Route
text
C25284 (NCI Thesaurus ValueDomain)
C0013153 (UMLS CUI-1)
C459 (NCI Thesaurus ObjectClass)
C25409 (NCI Thesaurus ObjectClass-2)
C25169 (NCI Thesaurus Property)
CL.3
Code List
Route
CL Item
Ear (Auricular)
C12394 (NCI Thesaurus)
C0013443 (UMLS 2011AA)
CL Item
Skin (Dermal)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Inhaled (Inhaled)
CL Item
Intra-articular (Intra-articular)
CL Item
Intramuscular (Intramuscular)
C27974 (NCI Thesaurus)
C0442117 (UMLS 2011AA)
C27974 (NCI Thesaurus-3)
C0442117 (UMLS 2011AA-4)
CL Item
Intranasal (Intranasal)
CL Item
Intravenous (intravenous)
X-MO-6794 (MGED)
X-MO-6794 (MGED-2)
CL Item
Not Specified (Not specified)
CL Item
Ocular (Ocular)
C0521414 (NCI Metathesaurus)
CL Item
Oral (oral)
C25311 (NCI Thesaurus)
C0442027 (UMLS 2011AA)
C25311 (NCI Thesaurus-3)
C0442027 (UMLS 2011AA-4)
CL Item
Rectal (rectal)
C25224 (NCI Thesaurus)
C0205052 (UMLS 2011AA)
CL Item
Subcutaneous (Subcutaneous)
C13353 (NCI Thesaurus)
C0443315 (UMLS 2011AA)
C13353 (NCI Thesaurus-3)
C0443315 (UMLS 2011AA-4)
CL Item
Sublingual (Sublingual)
C89785 (NCI Thesaurus)
CL Item
Vaginal (vaginal)
Item
Agent Administered Frequency
text
C1708 (NCI Thesaurus ObjectClass)
C3476109 (UMLS CUI-1)
C25515 (NCI Thesaurus ValueDomain)
C25382 (NCI Thesaurus Property)
CL.4
Code List
Agent Administered Frequency
CL Item
Am (AM)
CL Item
Daily (Daily)
C25473 (NCI Thesaurus)
C0332173 (UMLS 2011AA)
CL Item
Eight Times A Day (Eight times a day)
CL Item
Four Times A Day (q.i.d) (four times a day (Q.I.D))
CL Item
Not Specified (Not specified)
CL Item
Pm/bedtime (PM/bedtime)
CL Item
Six Times A Day (Six times a day)
CL Item
Three Times A Day (t.i.d) (three times a day (T.I.D))
CL Item
Twice A Day (b.i.d) (twice a day (B.I.D))
CL Item
When Needed (When needed)
ConcomitantMedicationStartDate
Item
Start Date
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25379 (NCI Thesaurus ObjectClass)
C0750729 (UMLS 2011AA ObjectClass)
CL219258 (NCI Metathesaurus Property)
ConcomitantMedicationAdministrationLastDate
Item
Date last taken
date
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)
Item
Ongoing?
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ValueDomain-2)
C0521116 (UMLS 2011AA ValueDomain-2)
CL.5
Code List
Ongoing?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Reason
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
CL.6
Code List
Reason
CL Item
Advertisement (Advertisement)
CL Item
Doctor Prescription (Doctor prescription)
CL Item
Holistic Advisement (Holistic advisement)
CL Item
New Condition (New condition)
CL Item
Non Medical Advise (Non medical advise)
CL Item
Unspecified (Not specified)
C38046 (NCI Thesaurus)
C0205370 (UMLS 2011AA)
CL Item
Own Description (Own description)
CL Item
Pre-existing Condition (Pre-existing condition)
Item Group
Comment
Research Comments
Item
COMMENT
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
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