GYNECOLOGIC PROCEDURES FORM (Form 24-GYN) Instructions: Complete this form if patient had gynecologic surgery, procedures and/or diagnostic imaging (excluding PAP smears and procedures related to diagnosis of cervical carcinoma in situ). Submit with the next scheduled Follow-Up (24-E) Form. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Report All Gynecologic Procedures Which Apply:
TransvaginalultrasoundDate
Item
Transvaginal ultrasound Date (D M Y)
text
DiagnosticImagingAbdominalPelvicUltrasoundImagingPerformedDate
Item
Abdominal/pelvic ultrasound Date (D M Y)
date
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25342 (NCI Thesaurus Property-2)
C0000726 (UMLS 2011AA Property-2)
C17230 (NCI Thesaurus Property-3)
C0041618 (UMLS 2011AA Property-3)
C25399 (NCI Thesaurus Property-4)
C0030797 (UMLS 2011AA Property-4)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
OtherimagingDate
Item
Other imaging Date (D M Y)
text
Otherimaging,specifysiteandtypeofimage
Item
Other imaging, specify site and type of image
text
Endometrialsamplingdate
Item
Screening endometrial sampling Date (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
HysterectomyPerformedDate
Item
Hysterectomy (date) (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15256 (NCI Thesaurus ObjectClass)
C0020699 (UMLS 2011AA ObjectClass)
UnilateralOophorectomyPerformedDate
Item
Unilateral oophorectomy Date (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C28012 (NCI Thesaurus ObjectClass)
C0205092 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15291 (NCI Thesaurus ObjectClass-2)
C0029936 (UMLS 2011AA ObjectClass-2)
BilateraloophorectomyDate
Item
Bilateral oophorectomy Date (D M Y)
text
Item
Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
text
CL.2
Code List
Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
CL Item
Ovarian Cancer Prevention (Ovarian cancer prevention)
CL Item
Breast Cancer Prevention (Breast cancer prevention)
C15553 (NCI Thesaurus)
C0281189 (UMLS 2011AA)
CL Item
Benign Gynecologic Condition (Benign gynecologic condition)
CL Item
Pre-malignancy (Pre-malignancy)
CL Item
Borderline Ovarian Tumor (Borderline ovarian tumor)
CL046614 (NCI Metathesaurus)
CL Item
Invasive Cancer (Invasive cancer)
CL Item
Other, Specify (Other, specify)
HysterectomyPerformedSpecify
Item
Other, specify (hysterectomy done)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15256 (NCI Thesaurus ObjectClass)
C0020699 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date (day month year)
date
InvestigatorSignatureDate
Item
Date (day month year)
date
Item
Pathologic Diagnosis
text
CL.1
Code List
Pathologic Diagnosis
CL Item
Negative (Negative)
CL Item
Invasive cancer (Invasive cancer)
CL Item
In situ cancer (In situ cancer)
CL Item
Simple cystic hyperplasia without atypia (Simple cystic hyperplasia without atypia)
CL Item
Simple cystic hyperplasia with atypia (Simple cystic hyperplasia with atypia)
CL Item
Complex/adenomatous hyperplasia without atypia (Complex/adenomatous hyperplasia without atypia)
CL Item
Complex/adenomatoushyperplasia with atypia (Complex/adenomatoushyperplasia with atypia)
CL Item
Non-diagnostic (Non-diagnostic)
Item Group
Ccrr Module For Gynecologic Procedures Form (form 24-gyn)
PatientStudyID,CoordinatingGroup
Item
Patient ID Number (Study No.)
text
Patient Initials
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientBirthDate
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
MainMemberInstitution/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
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