(For all B-36 Patients)

1 forms
  1. StudyEvent: NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire
    1. (For all B-36 Patients)
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)
Item Group
Date Questionnaire Completed
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed (Month Day Year)
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 Group
Section A
Item
Have you had your uterus removed?
text
CL.1
Code List
Have you had your uterus removed?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you had both your ovaries removed?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12404 (NCI Thesaurus ObjectClass)
C0029939 (UMLS 2011AA ObjectClass)
C25650 (NCI Thesaurus Property)
C0849355 (UMLS 2011AA Property)
CL.2
Code List
Have you had both your ovaries removed?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C3232 (NCI Thesaurus ObjectClass)
C0025344 (UMLS 2011AA ObjectClass)
CL.3
Code List
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Section B
Firstdayoflastmenstrualperiod
Item
When was your last menstrual period (or vaginal bleeding)? (Month Year)
text
Item
Did your periods stop or become less frequent during the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C3232 (NCI Thesaurus ObjectClass)
C0025344 (UMLS 2011AA ObjectClass)
C25496 (NCI Thesaurus Property-2)
C2746065 (UMLS 2011AA Property-2)
CL.4
Code List
Did your periods stop or become less frequent during the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15599 (NCI Thesaurus ObjectClass)
C0282402 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.5
Code List
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
Item
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C37932 (NCI Thesaurus Property)
C0700589 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
CL.6
Code List
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
Item Group
Ccrr Module For Nsabp Protocol B-36 Baseline Menstrual History Questionnaire
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