INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
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)
Registration Number
Item
Registration Step (Place ID Label Here)
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)
Patient Initials
Item
Patient Initials (Last, First)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
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)
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)
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)
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)
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)
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)
Item Group
On Treatment
Item
On Treatment Report Period (Choose one)
text
C25284 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C25214 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
Code List
On Treatment Report Period (Choose one)
CL Item
Baseline Step 1 (Baseline Step 1)
Item Group
Data amendment
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)
Data amended date
Item
Date data amended (s 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)
Item Group
Assessment Date
Assessment Date
Item
Date of Assessment
date
C25164 (NCI Thesaurus ValueDomain)
C2985720 (UMLS CUI-1)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C38000 (NCI Thesaurus Property)
Item Group
Mini Mental Examination Section
Mini-MentalStatusExamAdministeredTotalCount
Item
Total Score (ATTENTION AND CALCULATION 1 point for each correct answer Serial 7's: Have patient begin with 100 and count backward by 7. Stop after 5 answers. 1 point for each one correct. Or alternatively: spell 'world' backwards. Score by number of letters in correct order. LANGUAGE 1 point for each correct answer Show the patient the statement "Close your eyes" and have - him read and obey what it says. Have the patient write a sentence with a subject and verb. Have the patient copy the figure)
float
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C74982 (NCI Thesaurus ObjectClass)
C0451306 (UMLS 2011AA ObjectClass)
Item Group
Gds
PatientAnhedoniaAssessmentInd-2
Item
Do you feel that your life is empty
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C3673 (NCI Thesaurus Property-2)
C0178417 (UMLS 2011AA Property)
PatientHappinessAssessmentInd-2
Item
Do you feel happy most of the time
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0018592 (NCI Metathesaurus Property)
PatientHopelessnessAssessmentInd-2
Item
Do you often feel helpless
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C74531 (NCI Thesaurus Property-2)
C0150041 (UMLS 2011AA Property)
PatientWorthlessnessAssessmentInd-2
Item
Do you feel pretty worthless the way you are now
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C74535 (NCI Thesaurus Property-2)
C1821293 (UMLS 2011AA Property)
Item Group
Adl
Item
Bathing (sponge bath, tub bath or shower)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0150141 (NCI Metathesaurus ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Bathing (sponge bath, tub bath or shower)
CL Item
I Receive No Assistance (I receive no assistance)
CL Item
I Receive Assistance In Bathing Only One Part Of The Body (I receive assistance in bathing only one part of the body)
CL Item
I Receive Assistance In Bathing More Than One Part Of The Body (I receive assistance in bathing more than one part of the body)
Item
Transfer
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48167 (NCI Thesaurus ObjectClass-2)
C1705822 (UMLS 2011AA ObjectClass-2)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Transfer
CL Item
I Am Able To Move Into And Out Of Bed As Well As Into And Out Of Chair Without Assistance (I am able to move into and out of bed as well as into and out of chair without assistance)
CL Item
I Am Able To Move Into And Out Of Bed Or Chair With Assistance (I am able to move into and out of bed or chair with assistance)
CL Item
I Am Not Able To Get Out Of Bed (I am not able to get out of bed)
Item
Continence
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0021167 (NCI Metathesaurus ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Continence
CL Item
I Am Able To Control Urination And Bowel Movement Completely By Myself (I am able to control urination and bowel movement completely by myself)
CL Item
I Have Occasional Accidents (I have occasional accidents)
CL Item
I Need Someone To Help Me Keep Control Of Urination Or Bowel Movement Or A Catheter Is Used Or I Am Unable To Hold My Urine Or Bowel Movements (I need someone to help me keep control of urination or bowel movement OR a catheter is used OR I am unable to hold my urine or bowel movements)
Item
Can you go shopping for groceries
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C81006 (NCI Thesaurus ObjectClass-2)
C0150768 (UMLS 2011AA ObjectClass-2)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Can you go shopping for groceries
CL Item
Without Help (Without help)
CL Item
With Some Help (With some help)
CL Item
I Am Completely Unable To Do Any Shopping (I am completely unable to do any shopping)
Item
Can you prepare your own meals
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17604 (NCI Thesaurus ObjectClass-2)
C0920297 (UMLS 2011AA ObjectClass-2)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Can you prepare your own meals
CL Item
Without Help (Without help)
CL Item
With Some Help (With some help)
CL Item
I Am Completely Unable To Prepare Any Meals (I am completely unable to prepare any meals)
Item
Can you do your own housework
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C53291 (NCI Thesaurus ObjectClass-2)
C1708387 (UMLS 2011AA ObjectClass-2)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Can you do your own housework
CL Item
Without Help (Without help)
CL Item
With Help (With help)
CL Item
I Am Completely Unable To Do Any Housework (I am completely unable to do any housework)
Item
Can you do your own laundry
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C65077 (NCI Thesaurus ObjectClass-2)
C0441648 (UMLS 2011AA ObjectClass-2)
C0018896 (NCI Metathesaurus Property)
C25367 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Can you do your own laundry
CL Item
Without Help (Without help)
CL Item
With Help (With help)
CL Item
I Am Completely Unable To Do Any Laundry At All (I am completely unable to do any laundry at all)
Item
Someone you can count on to listen to you when you need to talk
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C71323 (NCI Thesaurus Property-3)
C2584313 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone you can count on to listen to you when you need to talk
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone whose advice you really want
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C60731 (NCI Thesaurus Property-3)
C1828381 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone whose advice you really want
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone whose advice you really want
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C60731 (NCI Thesaurus Property-3)
C1828381 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone whose advice you really want
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to share your most private worries and fears with
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C43367 (NCI Thesaurus Property-3)
C1704726 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to share your most private worries and fears with
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to share your most private worries and fears with
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C43367 (NCI Thesaurus Property-3)
C1704726 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to share your most private worries and fears with
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to turn to for suggestions about how to deal with a personal problem
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C48191 (NCI Thesaurus Property-3)
C1533716 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to turn to for suggestions about how to deal with a personal problem
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to turn to for suggestions about how to deal with a personal problem
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C48191 (NCI Thesaurus Property-3)
C1533716 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to turn to for suggestions about how to deal with a personal problem
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone who understands your problems
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-2)
C72889 (NCI Thesaurus Property-4)
C2346843 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone who understands your problems
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item Group
Section Ii - Social Support
Item
Someone to help you if you were confined to bed
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C45985 (NCI Thesaurus Property-3)
C0004910 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to help you if you were confined to bed
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to take you to the doctor if you needed it
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C61560 (NCI Thesaurus Property-3)
C16988 (NCI Thesaurus Property-4)
C0031834 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to take you to the doctor if you needed it
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to prepare your meals if you were unable to do it yourself
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C62695 (NCI Thesaurus Property-3)
C0016452 (UMLS 2011AA Property-2)
C25625 (NCI Thesaurus Property-4)
C1521827 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to prepare your meals if you were unable to do it yourself
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to help with daily chores if you were sick
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C37902 (NCI Thesaurus Property-2)
C1521721 (UMLS 2011AA Property)
C53291 (NCI Thesaurus Property-3)
C1708387 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Someone to help with daily chores if you were sick
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item Group
Comorbidity Questionnaire
PatientPriorMyocardialInfarctionInd-3
Item
Have you ever had a heart attack
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27996 (NCI Thesaurus Property)
C0027051 (UMLS 2011AA Property)
C25629 (NCI Thesaurus Property-2)
C0332152 (UMLS 2011AA Property-2)
CongestiveHeartFailureHistoryInd-2
Item
Have you ever been treated for heart failure (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C3080 (NCI Thesaurus ObjectClass)
C0018802 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
HeartInvolvedInd-3
Item
Do you have other heart disease
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12727 (NCI Thesaurus ObjectClass)
C0018787 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)
OtherPeripheralArteryDiseasePresentInd-3
Item
Have you had an operation to unclog or bypass arteries in your legs
boolean
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C12372 (NCI Thesaurus ObjectClass-3)
C0003842 (UMLS 2011AA ObjectClass-3)
C25233 (NCI Thesaurus ObjectClass-4)
C0205100 (UMLS 2011AA ObjectClass-4)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
PatientTransientIschemicAttackCerebrovascularAccidentPersonalMedicalHistoryInd-2
Item
Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)
boolean
C29867 (NCI Thesaurus ObjectClass)
C0679646 (UMLS 2011AA ObjectClass)
C50781 (NCI Thesaurus Property)
C0007787 (UMLS 2011AA Property)
C3390 (NCI Thesaurus Property-2)
C0038454 (UMLS 2011AA Property-2)
C18772 (NCI Thesaurus Property-3)
C0262926 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientCerebrovascularAccidentMovementDifficultyPresentInd-2
Item
Do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident (If yes)
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C3390 (NCI Thesaurus Property-2)
C0038454 (UMLS 2011AA Property-2)
C37994 (NCI Thesaurus Property-3)
C0026649 (UMLS 2011AA Property-3)
C62189 (NCI Thesaurus Property-4)
C1299586 (UMLS 2011AA Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
AsthmaHistoryInd-2
Item
Do you have asthma
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C28397 (NCI Thesaurus ObjectClass)
C0004096 (UMLS 2011AA ObjectClass)
Item
Do you take medicines for your asthma (If yes check one box)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus Property)
C0013227 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C28397 (NCI Thesaurus ObjectClass)
C0004096 (UMLS 2011AA ObjectClass)
Code List
Do you take medicines for your asthma (If yes check one box)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Only With Flare-ups Of My Asthma (Yes, only with flare-ups of my asthma)
CL Item
Yes, I Take Medicines Regularly Even When I'm Not Having A Flare-up (Yes, I take medicines regularly even when I'm not having a flare-up)
DiseaseEmphysemaBronchitisPresentInd-3
Item
Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease
boolean
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2911 (NCI Thesaurus Property-2)
C0006277 (UMLS 2011AA Property-2)
C3348 (NCI Thesaurus Property-3)
C0034067 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Item
Do you take medicines for your lung disease (If yes check one box)
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C49236 (NCI Thesaurus ObjectClass-2)
C0087111 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2911 (NCI Thesaurus Property-2)
C0006277 (UMLS 2011AA Property-2)
C3348 (NCI Thesaurus Property-3)
C0034067 (UMLS 2011AA Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Do you take medicines for your lung disease (If yes check one box)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Only With Flare-ups Of My Lung Disease (Yes, only with flare-ups of my lung disease)
CL Item
Yes, I Take Medicines Regularly Even When I'm Not Having A Flare-up (Yes, I take medicines regularly even when I'm not having a flare-up)
Item Group
Comorbidity Questionnaire1
DiseaseStomachPresentInd-3
Item
Do you have stomach ulcers, or peptic ulcer disease
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12391 (NCI Thesaurus Property-2)
C0038351 (UMLS 2011AA Property-2)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
DiabetesMellitusDiseasesandDisordersMedicationBaselineUseInd-2
Item
Do you have diabetes (high blood sugar)
boolean
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C2985 (NCI Thesaurus ObjectClass-2)
C0011849 (UMLS 2011AA ObjectClass-2)
C459 (NCI Thesaurus ObjectClass-3)
C0013227 (UMLS 2011AA ObjectClass-3)
C25213 (NCI Thesaurus Property)
C1442488 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
How is it treated (If yes check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2985 (NCI Thesaurus ObjectClass)
C0011849 (UMLS 2011AA ObjectClass)
C49236 (NCI Thesaurus Property-2)
C0087111 (UMLS 2011AA Property-2)
Code List
How is it treated (If yes check one box)
CL Item
Treated By Modifying My Diet (Treated by modifying my diet)
CL Item
Treated By Medications Taken By Mouth (Treated by medications taken by mouth)
CL Item
Treated By Insulin Injections (Treated by insulin injections)
Item
Has the diabetes caused any of the following problems (If yes)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2985 (NCI Thesaurus Property)
C0011849 (UMLS 2011AA Property)
C2959 (NCI Thesaurus Property-2)
C0009566 (UMLS 2011AA Property-2)
C13018 (NCI Thesaurus Property-3)
C0178784 (UMLS 2011AA Property-3)
C18772 (NCI Thesaurus Property-4)
C0262926 (UMLS 2011AA Property-4)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Has the diabetes caused any of the following problems (If yes)
CL Item
Problems With Your Kidneys (Problems with your kidneys)
CL Item
Problems With Your Eyes, Treated By An Ophthamologist (Problems with your eyes, treated by an ophthamologist)
CL Item
Problems With Numbness Or Tingling In Your Feet Or Legs (Problems with numbness or tingling in your feet or legs)
Item
Have you ever had the following problems with your kidneys
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12415 (NCI Thesaurus ObjectClass)
C0022646 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
Code List
Have you ever had the following problems with your kidneys
CL Item
Poor Kidney Function (Poor kidney function)
CL Item
Have Used Dialysis (Have used dialysis)
CL Item
Have Received Kidney Transplantation (Have received kidney transplantation)
PatientArthritisPersonalMedicalHistoryInd-3
Item
Do you have arthritis
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2883 (NCI Thesaurus Property)
C0003864 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
ConcomitantMedicationUseInd-3
Item
Do you take medications for it regularly (If yes)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
Item
Do you have any of the following conditions
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
Code List
Do you have any of the following conditions
CL Item
Alzheimer's Disease, Or Another Form Of Dementia (Alzheimer's Disease, or another form of dementia)
CL Item
Cirrhosis, Hepatitis, Or Serious Liver Disease (Cirrhosis, hepatitis, or serious liver disease)
CL Item
Anemia (Anemia)
C2869 (NCI Thesaurus)
C0002871 (UMLS 2011AA)
CL Item
Depression (Depression)
C2982 (NCI Thesaurus)
C0011570 (UMLS 2011AA)
CL Item
Chronic Sinus Infections (Chronic sinus infections)
CL Item
Chronic Back Pain (Chronic back pain)
CL Item
Osteoporosis (Osteoporosis)
C3298 (NCI Thesaurus)
C0029456 (UMLS 2011AA)
CL Item
Dental Problems (Dental Problems)
CL Item
Cancer (Cancer)
Item
How often do you see your dentist
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C52654 (NCI Thesaurus Property)
C0011441 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property-2)
C0545082 (UMLS 2011AA Property-2)
Code List
How often do you see your dentist
CL Item
Every 6-12 Months (Every 6-12 months)
CL Item
Every 1-2 Years (Every 1-2 years)
CL Item
I Don't See A Dentist (I don't see a dentist)
ChronicDiseaseDiagnosisSpecify
Item
Please list any other health problems you have in the space below
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
Item Group
Medications/sexual Function
Item
On average, how many prescription medicines do you take each day
text
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C28180 (NCI Thesaurus ObjectClass-2)
C1521941 (UMLS 2011AA ObjectClass-2)
C25730 (NCI Thesaurus ObjectClass-3)
C0521115 (UMLS 2011AA ObjectClass-3)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Code List
On average, how many prescription medicines do you take each day
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1-3 (1-3)
CL Item
4-6 (4-6)
CL Item
7-10 (7-10)
CL Item
More Than 10 (More than 10)
Item
On average, how many non-prescription medicines (over-the-counter) do you take each day
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
Code List
On average, how many non-prescription medicines (over-the-counter) do you take each day
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1-3 (1-3)
CL Item
4-6 (4-6)
CL Item
7-10 (7-10)
CL Item
More Than 10 (More than 10)
Item
During the last 4 weeks, did you have sexual intercourse
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)
Code List
During the last 4 weeks, did you have sexual intercourse
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Once (Yes, once)
CL Item
Yes, More Than Once (Yes, more than once)
Item
Over the past 4 weeks, how would you rate your level of sexual desire
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass-2)
C0036864 (UMLS 2011AA ObjectClass-2)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C62185 (NCI Thesaurus Property-3)
C0242428 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Over the past 4 weeks, how would you rate your level of sexual desire
CL Item
Very Low/none At All (Very low/none at all)
CL Item
Low (Low)
C54722 (NCI Thesaurus)
C0205251 (UMLS 2011AA)
CL Item
Moderation (Moderate)
C61376 (NCI Thesaurus)
C1881878 (UMLS 2011AA)
CL Item
High (High)
C25227 (NCI Thesaurus)
C0205250 (UMLS 2011AA)
CL Item
Very High (Very high)
Item Group
Weight
PatientNormalWeightMeasurement
Item
What is your usual weight
float
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C14165 (NCI Thesaurus Property)
C0205307 (UMLS 2011AA Property)
C25208 (NCI Thesaurus Property-2)
C0043100 (UMLS 2011AA Property-2)
PatientWeightLossMeasurement
Item
How much weight have you lost in the past 6 months
float
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3445 (NCI Thesaurus Property)
C1262477 (UMLS 2011AA Property)

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