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1 forms
  1. StudyEvent: GOG-0252 Medical History Form (Form MEDH)
    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
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
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
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)
Item Group
Ovarian: Disease Description
Item
Have you ever been treated for hypertension that required medication
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C3117 (NCI Thesaurus Property)
C0020538 (UMLS 2011AA Property)
C49236 (NCI Thesaurus Property-2)
C0087111 (UMLS 2011AA Property-2)
C18772 (NCI Thesaurus Property-3)
C0262926 (UMLS 2011AA Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.1
Code List
Have you ever been treated for hypertension that required medication
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Currently (Yes, currently)
CL Item
Yes, In The Past (Yes, in the past)
HistoryofPeripheralVascularDiseasePresentInd-3
Item
Peripheral vascular disease with claudication
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C66923 (NCI Thesaurus ObjectClass)
C1881056 (UMLS 2011AA ObjectClass)
PatientCerebrovascularAccidentMyocardialInfarctionPersonalMedicalHistoryInd-3
Item
Myocardial infarction or cerebrovascular accident
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27996 (NCI Thesaurus Property)
C0027051 (UMLS 2011AA Property)
C3390 (NCI Thesaurus Property-2)
C0038454 (UMLS 2011AA Property-2)
C18772 (NCI Thesaurus Property-3)
C0262926 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Current Smoker
Item
Have you smoked during the past year
boolean
C38148 (NCI Thesaurus ValueDomain)
C3241966 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C17934 (NCI Thesaurus ObjectClass)
C0449865 (NCI Metathesaurus Property)
CigaretteAverageDailyPackUseCount
Item
If you smoke, how many packs of cigarettes do you average per day
float
C1802 (NCI Thesaurus ObjectClass)
C0677453 (UMLS 2011AA ObjectClass)
C25473 (NCI Thesaurus Property)
C0332173 (UMLS 2011AA Property)
C62653 (NCI Thesaurus Property-2)
C2825051 (UMLS 2011AA Property-2)
C37917 (NCI Thesaurus Property-3)
C1510992 (UMLS 2011AA Property-3)
C25340 (NCI Thesaurus Property-4)
C0457083 (UMLS 2011AA Property-4)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
CigarAverageDailyUseCount
Item
How many cigars/pipes do you average per day
float
C1813 (NCI Thesaurus ObjectClass)
C0182504 (UMLS 2011AA ObjectClass)
C25473 (NCI Thesaurus Property)
C0332173 (UMLS 2011AA Property)
C37917 (NCI Thesaurus Property-2)
C1510992 (UMLS 2011AA Property-2)
C25340 (NCI Thesaurus Property-3)
C0457083 (UMLS 2011AA Property-3)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Smoking Duration
Item
How many years have you smoked
float
C25463 (NCI Thesaurus ValueDomain)
C3694955 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C25330 (NCI Thesaurus Property)
Item
Do you currently take medication for diabetes
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C2985 (NCI Thesaurus Property)
C0011849 (UMLS 2011AA Property)
C49236 (NCI Thesaurus Property-2)
C0087111 (UMLS 2011AA Property-2)
C18772 (NCI Thesaurus Property-3)
C0262926 (UMLS 2011AA Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.5
Code List
Do you currently take medication for diabetes
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes - Insulin (Yes - Insulin)
CL Item
Yes - Oral Hypoglycemics (Yes - Oral hypoglycemics)
Item Group
Ovarian: Findings From Primary Surgery
DiseasesandDisordersPatientSelf-ReportAutoimmuneDiseaseDiagnosisInd-3
Item
Have you ever been diagnosed with an autoimmune disease
boolean
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C2889 (NCI Thesaurus Property-2)
C0004364 (UMLS 2011AA Property-2)
C21089 (NCI Thesaurus Property-3)
C0681906 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Item Group
Ovarian: Post-operative Findings Following Primary Surgery
PatientUlcerationPersonalMedicalHistoryInd-3
Item
Have you ever had peptic ulcer disease, documented by endoscopy
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C25757 (NCI Thesaurus Property-2)
C0041582 (UMLS 2011AA Property-2)
TumorIntestinalObstructionInd-3
Item
Have you ever had an intestinal obstruction, documented radiographically
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25266 (NCI Thesaurus Property)
C0021853 (UMLS 2011AA Property)
C3284 (NCI Thesaurus Property-2)
C0028778 (UMLS 2011AA Property-2)
Item
Have you ever had inflammatory bowel disease
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3138 (NCI Thesaurus Property)
C0021390 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
CL.9
Code List
Have you ever had inflammatory bowel disease
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes - Crohn's Disease (Yes - Crohn's disease)
CL Item
Yes - Ulcerative Colitis (Yes - Ulcerative colitis)
PatientInflammatoryBowelDiseaseTreatmentPersonalMedicalHistoryInd-2
Item
If you have had inflammatory bowel disease, did you require medication and/or surgery
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
C3138 (NCI Thesaurus Property-2)
C0021390 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-3)
C0262926 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientDiverticulitisTreatmentPersonalMedicalHistoryInd-2
Item
Have you ever had diverticulitis that required hospitalization or outpatient antibiotics and dietary modification
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property)
C26752 (NCI Thesaurus Property-3)
C0012813 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientC.DifficileColitisPersonalMedicalHistoryInd-2
Item
Have you ever had C. difficile colitis
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C35286 (NCI Thesaurus Property-2)
C0238106 (UMLS 2011AA Property-2)
PatientSmallIntestineExcisionAnastomosisPersonalMedicalHistoryInd-2
Item
Have you ever had small bowel resection with anastomosis
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12386 (NCI Thesaurus Property)
C0021852 (UMLS 2011AA Property)
C15609 (NCI Thesaurus Property-2)
C0677554 (UMLS 2011AA Property-2)
C15232 (NCI Thesaurus Property-3)
C0728940 (UMLS 2011AA Property-3)
C18772 (NCI Thesaurus Property-4)
C0262926 (UMLS 2011AA Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientSmallBowelExcisionAnastomosisDebulkingPersonalMedicalHistoryInd-2
Item
At primary debulking surgery
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12386 (NCI Thesaurus Property)
C0021852 (UMLS 2011AA Property)
C15609 (NCI Thesaurus Property-2)
C0677554 (UMLS 2011AA Property-2)
C15232 (NCI Thesaurus Property-3)
C0728940 (UMLS 2011AA Property-3)
C18772 (NCI Thesaurus Property-4)
C0262926 (UMLS 2011AA Property-4)
C15749 (NCI Thesaurus Property-5)
C0439805 (UMLS 2011AA Property-5)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientLargeIntestineExcisionAnastomosisPersonalMedicalHistoryInd-2
Item
Have you ever had large bowel resection with anastomosis
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C15609 (NCI Thesaurus Property)
C0677554 (UMLS 2011AA Property)
C12379 (NCI Thesaurus Property-2)
C0021851 (UMLS 2011AA Property-2)
C15232 (NCI Thesaurus Property-3)
C0728940 (UMLS 2011AA Property-3)
C18772 (NCI Thesaurus Property-4)
C0262926 (UMLS 2011AA Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientLargeIntestineExcisionAnastomosisDebulkingPersonalMedicalHistoryInd-2
Item
At primary debulking surgery
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C15609 (NCI Thesaurus Property)
C0677554 (UMLS 2011AA Property)
C12379 (NCI Thesaurus Property-2)
C0021851 (UMLS 2011AA Property-2)
C15232 (NCI Thesaurus Property-3)
C0728940 (UMLS 2011AA Property-3)
C18772 (NCI Thesaurus Property-4)
C0262926 (UMLS 2011AA Property-4)
C15749 (NCI Thesaurus Property-5)
C0439805 (UMLS 2011AA Property-5)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item Group
Footer Module
PatientCorticosteroidUsePersonalMedicalHistoryInd-2
Item
Do you use corticosteroids for a chronic condition
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2322 (NCI Thesaurus Property)
C0001617 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C25340 (NCI Thesaurus Property-3)
C0457083 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientNonsteroidalAntiinflammatoryDrugRegularUsePersonalMedicalHistoryInd-2
Item
Do you use NSAID chronically
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C257 (NCI Thesaurus Property-2)
C0003211 (UMLS 2011AA Property-2)
C25340 (NCI Thesaurus Property-3)
C0457083 (UMLS 2011AA Property-3)
C25647 (NCI Thesaurus Property-4)
C0205272 (UMLS 2011AA Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item Group
Comments
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
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