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1 forms
  1. StudyEvent: Gynecologic Oncology Group Smoking History Questionnaire (Form SHQ)
    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 (m d y)
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 (m d y)
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)
Last Name
Item
Patient Name, Last
text
C25191 (NCI Thesaurus ValueDomain)
C1301584 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
First Name
Item
Patient Name, First
text
C25191 (NCI Thesaurus ValueDomain)
C1443235 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
Patient ID GOG
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512288 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25521 (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
Smoking History Questionnaire
TobaccoSmokingHistoryIndicator
Item
Have you ever smoked tobacco products?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
Item Group
Personal Smoking Section
Item
Have you smoked at least 100 cigarette during your lifetime
text
C25180 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C20989 (NCI Thesaurus Property)
C29719 (NCI Thesaurus ObjectClass)
CL.2
Code List
Have you smoked at least 100 cigarette during your lifetime
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, But Quit (Yes, but quit)
CL Item
Yes, Currently Smoke (Yes, currently smoke)
SmokingCessationNicotinePatchNicotineGumUseInd-2
Item
Are you currently using nicotine skin patches or gum
boolean
C17427 (NCI Thesaurus ObjectClass)
C0085134 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C17955 (NCI Thesaurus Property-2)
C0358855 (UMLS 2011AA Property-2)
C15663 (NCI Thesaurus Property-3)
C0068722 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientInitialCigaretteSmokingAgeYearCount
Item
How old were you when you smoked your first cigarette
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property-2)
C0700219 (UMLS 2011AA Property-2)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
CigaretteAverageDailyUseCount
Item
On average, how many cigarettes do/did you smoke per day
float
C1802 (NCI Thesaurus ObjectClass)
C0677453 (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)
PersonCigaretteWeekCurrentUseSmokingHistoryInd-2
Item
Are you still smoking at least one cigarette per week
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C1802 (NCI Thesaurus Property-2)
C0677453 (UMLS 2011AA Property-2)
C29844 (NCI Thesaurus Property-3)
C0439230 (UMLS 2011AA Property-3)
C29719 (NCI Thesaurus Property-4)
C1519384 (UMLS 2011AA Property-4)
C25340 (NCI Thesaurus Property-5)
C0457083 (UMLS 2011AA Property-5)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PersonCigaretteSmokingCessationAgeYearCount
Item
If you are no longer smoking, how old were you when you stopped smoking (years old)
float
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C1802 (NCI Thesaurus Property)
C0677453 (UMLS 2011AA Property)
C17427 (NCI Thesaurus Property-2)
C0085134 (UMLS 2011AA Property-2)
C25150 (NCI Thesaurus Property-3)
C0001779 (UMLS 2011AA Property-3)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item Group
Household Smoking Section
PersonHouseholdYearPassiveSmokeExposureInd-2
Item
Have you ever lived for at least a year in the same household with someone who smoked cigarettes regularly
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus Property)
C0439234 (UMLS 2011AA Property)
C41194 (NCI Thesaurus Property-2)
C0020052 (UMLS 2011AA Property-2)
C17140 (NCI Thesaurus Property-3)
C0037370 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PersonHouseholdYearPassiveSmokeExposureYearCount
Item
For about how many years, in total, have you lived with someone who smoked cigarettes regularly at the time (years)
float
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus Property)
C0439234 (UMLS 2011AA Property)
C41194 (NCI Thesaurus Property-2)
C0020052 (UMLS 2011AA Property-2)
C17140 (NCI Thesaurus Property-3)
C0037370 (UMLS 2011AA Property-3)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
PersonCurrentHouseholdCigarettePassiveSmokeExposureInd-2
Item
Do you now live in the same household with someone who smokes cigarettes regularly
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C1802 (NCI Thesaurus Property-2)
C0677453 (UMLS 2011AA Property-2)
C41194 (NCI Thesaurus Property-3)
C0020052 (UMLS 2011AA Property-3)
C17140 (NCI Thesaurus Property-4)
C0037370 (UMLS 2011AA Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PersonCurrentHouseholdCigarettePassiveSmokeExposureDayCount
Item
On average, how many cigarettes per day are smoked by other people while you are at home (cigarettes/day)
float
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C1802 (NCI Thesaurus Property-2)
C0677453 (UMLS 2011AA Property-2)
C41194 (NCI Thesaurus Property-3)
C0020052 (UMLS 2011AA Property-3)
C17140 (NCI Thesaurus Property-4)
C0037370 (UMLS 2011AA Property-4)
C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item Group
Second Hand Smoking Section
PersonCurrentExternalHouseholdCigarettePassiveSmokeExposureInd-2
Item
Are you exposed to smoke from another person's cigarettes at least once per week when you are outside of your household
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C1802 (NCI Thesaurus Property-2)
C0677453 (UMLS 2011AA Property-2)
C44280 (NCI Thesaurus Property-3)
C0205101 (UMLS 2011AA Property-3)
C41194 (NCI Thesaurus Property-4)
C0020052 (UMLS 2011AA Property-4)
C17140 (NCI Thesaurus Property-5)
C0037370 (UMLS 2011AA Property-5)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PersonCurrentExternalHouseholdCigaretteHourWeekPassiveSmokeExposureCount
Item
On average, how many hours per week are you exposed to smoke from other person's cigarettes outside of your household (hours/week)
float
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C1802 (NCI Thesaurus Property-2)
C0677453 (UMLS 2011AA Property-2)
C44280 (NCI Thesaurus Property-3)
C0205101 (UMLS 2011AA Property-3)
C25529 (NCI Thesaurus Property-4)
C0439227 (UMLS 2011AA Property-4)
C29844 (NCI Thesaurus Property-5)
C0439230 (UMLS 2011AA Property-5)
C41194 (NCI Thesaurus Property-6)
C0020052 (UMLS 2011AA Property-6)
C17140 (NCI Thesaurus Property-7)
C0037370 (UMLS 2011AA Property-7)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (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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