QUALITY OF LIFE MODULE FOR TRIAL 24-02 (Form 24-QLM) Patient Instructions: We would like to know how strongly you are affected by your illness and treatment. Please answer the following questions by placing a vertical mark on the line depending on how you assess yourself. (See the example on the Quality of Life Core Questionnaire.) Your information will be treated as strictly confidential. Thank you for replying!

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Within The Last Two Weeks, How Severe Have The Following Problems Been?
Item
Being irritable
integer
C25688 (NCI Thesaurus ValueDomain)
C0022107 (UMLS CUI-1)
CL.1
Code List
Being irritable
CL Item
None (0)
CL Item
Severe (1)
Item
Sweats (including night sweats including night)
integer
C25688 (NCI Thesaurus ValueDomain)
C0038990 (UMLS CUI-1)
CL.2
Code List
Sweats (including night sweats including night)
CL Item
None (0)
CL Item
Severe (1)
Item
Vaginal discharge
integer
C25688 (NCI Thesaurus ValueDomain)
C0227791 (UMLS CUI-1)
CL.3
Code List
Vaginal discharge
CL Item
None (0)
CL Item
Severe (1)
Item
Vaginal dryness
integer
C25688 (NCI Thesaurus ValueDomain)
CL.4
Code List
Vaginal dryness
CL Item
None (0)
CL Item
Severe (1)
Item
Vaginal itching / irritation
integer
C25688 (NCI Thesaurus ValueDomain)
CL.5
Code List
Vaginal itching / irritation
CL Item
None (0)
CL Item
Severe (1)
Item
Sleep disturbance
integer
C25688 (NCI Thesaurus ValueDomain)
CL.6
Code List
Sleep disturbance
CL Item
None (0)
CL Item
Severe (1)
Item
Feeling dizzy
integer
C25688 (NCI Thesaurus ValueDomain)
C0012833 (UMLS CUI-1)
CL.7
Code List
Feeling dizzy
CL Item
None (0)
CL Item
Severe (1)
Item
Headaches
integer
C25626 (NCI Thesaurus Property)
C34661 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0018681 (UMLS CUI-1)
CL.8
Code List
Headaches
CL Item
None (0)
CL Item
Severe (1)
Item
Bone or joint pain
integer
C25688 (NCI Thesaurus ValueDomain)
C0151825 (UMLS CUI-1)
C0003862 (UMLS CUI-2)
CL.9
Code List
Bone or joint pain
CL Item
None (0)
CL Item
Severe (1)
Item
Troubled by weight gain
integer
C25688 (NCI Thesaurus ValueDomain)
CL.10
Code List
Troubled by weight gain
CL Item
None (0)
CL Item
Severe (1)
Item
Loss of sexual interest
integer
C25688 (NCI Thesaurus ValueDomain)
CL.11
Code List
Loss of sexual interest
CL Item
None (0)
CL Item
Severe (1)
Item
Overall, how much are you bothered by any treatment related difficulties?
integer
CL.12
Code List
Overall, how much are you bothered by any treatment related difficulties?
CL Item
Not At All (0)
CL Item
Severely (1)
Sexually active past 6 months
Item
Have you been sexually active during the past six months?
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
Did you have difficulties in becoming aroused?
integer
C25688 (NCI Thesaurus ValueDomain)
CL.14
Code List
Did you have difficulties in becoming aroused?
CL Item
None (0)
CL Item
Severe (1)
Item Group
Ccrr Module For Quality Of Life Module For Trial 24-02 (form 24-qlm)
Patient ID
Item
Patient ID Number (Study No.)
text
C1549740 (UMLS CUI-1)
Patient Initials
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
Patient Birth Date
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0421451 (UMLS CUI-1)
Main Member Institution or Affiliate
Item
Participating Center/Affiliate
text
Center Code
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0565990 (UMLS CUI-1)
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