INSTRUCTIONS TO THE INSTITUTION This questionnaire should be completed by all patients. This form should be completed after the patient has signed the B-47 consent forms, but before randomization. A clinical staff member should complete page 1, print the patient's initials at the top of Pages 2 through 5, and give the questionnaire to the patient for completion. After the patient has completed the questionnaire, verify that the date the questionnaire was completed is recorded at the top of page 2. After the patient has been randomized, print the NSABP Patient ID at the top of pages 2 through 5 and fax all 5 pages to the NSABP Biostatistical Center at (412) 622-2115

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Patient Initials
Item
Patient Initials (Last First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (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)
Institution Number
Item
Institution Number
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
PersonFormAdministrationLastName
Item
Staff member administering form, Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)
PersonFormAdministrationFirstName
Item
Staff member administering form, first name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25509 (NCI Thesaurus ValueDomain-2)
C1279901 (UMLS 2011AA ValueDomain-2)
PersonFormAdministrationPhoneNumber
Item
Staff Member Administering Form, Phone
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
Data amended
Item
Are data amended (If yes, check the box and circle amended items)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Time Point
Item
This form is being filled out (mark one)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property-2)
C0205197 (UMLS 2011AA Property-2)
CL.2
Code List
This form is being filled out (mark one)
CL Item
By Clinical Staff On Phone With Participant (By clinical staff on phone with participant)
CL Item
By Patient In Doctor's Office (By participant in doctor's office)
CL Item
By Participant Not In Doctor's Office (By participant not in doctor's office)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed (Month Day Year)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
Item Group
Section 1 - Lifetime Medical Conditions
Item
Problem
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)
CL.3
Code List
Problem
CL Item
Anemia (Anemia or other blood disease)
E10010 (CTCAE)
CL Item
Atrial Fibrillation (Atrial fibrillation)
E10081 (CTCAE)
CL Item
Back Pain (Back pain)
E12388 (CTCAE)
CL Item
Osteoporosis (Bone loss or osteoporosis)
E12508 (CTCAE)
CL Item
Malignant Neoplasm (Cancer (other than breast or non-melanoma skin cancer))
C9305 (NCI Thesaurus)
C0006826 (UMLS 2011AA)
CL Item
Congestive Heart Failure (Congestive Heart Failure)
C3080 (NCI Thesaurus)
C0018802 (UMLS 2011AA)
CL Item
Depression (Depression)
C2982 (NCI Thesaurus)
C0011570 (UMLS 2011AA)
CL Item
Diabetes Mellitus (Diabetes)
C2985 (NCI Thesaurus)
C0011849 (UMLS 2011AA)
CL Item
Myocardial Infarction (Heart attack (myocardial infarction))
E10152 (CTCAE)
CL Item
Coronary Disease (Heart disease)
C26732 (NCI Thesaurus)
C0010068 (UMLS 2011AA)
CL Item
Hypertension (High blood pressure)
E13785 (CTCAE)
CL Item
Disease Or Disorder Kidney (Kidney disease)
C12415 (NCI Thesaurus)
C0022646 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
CL Item
Disease Or Disorder Liver (Liver disease)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
CL Item
Disease Or Disorder Pulmonary (Lung disease)
C13304 (NCI Thesaurus)
C2709248 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
CL Item
Osteoarthritis (Osteoarthritis, degenerative arthritis)
C3293 (NCI Thesaurus)
C0029408 (UMLS 2011AA)
CL Item
Arrhythmia (Other heart rhythm problem)
C2881 (NCI Thesaurus)
C0003811 (UMLS 2011AA)
CL Item
Rheumatoid Arthritis (Rheumatoid Arthritis)
C2884 (NCI Thesaurus)
C0003873 (UMLS 2011AA)
CL Item
Stroke (Stroke)
E12826 (CTCAE)
CL Item
Disease Or Disorder Thyroid Gland (Thyroid disease)
C12400 (NCI Thesaurus)
C0040132 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
CL Item
Ulcer (Ulcer or stomach disease)
C3426 (NCI Thesaurus)
C0041582 (UMLS 2011AA)
DiseaseorDisorderPhysicianCareAssessmentAssessmentInd-3
Item
Have you ever seen a doctor for the problem?
boolean
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25741 (NCI Thesaurus Property)
C0031831 (UMLS 2011AA Property)
C25217 (NCI Thesaurus Property-2)
C1516048 (UMLS 2011AA Property-2)
C61488 (NCI Thesaurus Property-3)
C1947933 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
PatientMedicalConditionTherapyInd-2
Item
Do you currently receive treatment for it?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25457 (NCI Thesaurus Property-2)
C0348080 (UMLS 2011AA Property-2)
PersonDiseaseorDisorderActivityRestrictionAssessmentInd-3
Item
Does it now limit your activities?
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C43431 (NCI Thesaurus Property-2)
C0441655 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property-3)
C0012634 (UMLS 2011AA Property-2)
C53452 (NCI Thesaurus Property-4)
C0443288 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Item Group
Section 2 - Tobacco Usage
Smoking history
Item
Have you smoked at least 100 cigarettes in your entire life? (100 cigarettes = 5 packs)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C18772 (NCI Thesaurus Property)
Tobaccootheruseindicator
Item
Have you used other forms of tobacco regularly
boolean
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C891 (NCI Thesaurus ObjectClass-2)
C0040329 (UMLS 2011AA ObjectClass-2)
C691 (NCI Thesaurus ObjectClass-3)
C0028040 (UMLS 2011AA ObjectClass-3)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
Have you used other forms of tobacco regularly (Check all that apply)
text
C25284 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
CL.9
Code List
Have you used other forms of tobacco regularly (Check all that apply)
CL Item
Chew Tobacco (Chew tobacco)
CL Item
Cigar (Cigar)
C1813 (NCI Thesaurus)
C0182504 (UMLS 2011AA)
CL Item
Pipe (Pipe)
CL Item
Other, Specify (Other, specify)
PatientInitialCigaretteSmokingAgeYearCount
Item
How old were you when you started using tobacco (In years)
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)
Item
Did you use tobacco (In the past week)
text
C25284 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C18772 (NCI Thesaurus Property)
CL.10
Code List
Did you use tobacco (In the past week)
CL Item
No, Not At All (No, not at all)
CL Item
Yes, Every Day (Yes, every day)
CL Item
Yes, Some Days (Yes, some days)
Item
On about how many days did you use tobacco (During the period of your life when you used tobacco, think about a typical month)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C17934 (NCI Thesaurus ObjectClass-2)
C0453996 (UMLS 2011AA ObjectClass-2)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
CL.11
Code List
On about how many days did you use tobacco (During the period of your life when you used tobacco, think about a typical month)
CL Item
1 - 2 Days (1 - 2 days)
CL Item
3 - 5 Days (3 - 5 days)
CL Item
6 - 9 Days (6 - 9 days)
CL Item
10 - 19 Days (10 - 19 days)
CL Item
20 - 29 Days (20 - 29 days)
CL Item
Every Day (Every day)
Item
On the days you did smoke, what was the average number of cigarettes you smoked per day (Think about a typical month when you smoked cigarettes)
text
C17934 (NCI Thesaurus ObjectClass)
C1608325 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C0449865 (NCI Metathesaurus Property)
C25473 (NCI Thesaurus ValueDomain)
C25515 (NCI Thesaurus ValueDomain-2)
CL.12
Code List
On the days you did smoke, what was the average number of cigarettes you smoked per day (Think about a typical month when you smoked cigarettes)
CL Item
Fewer Than 10 Cigarettes (Fewer than 10 cigarettes)
CL Item
10 To 20 Cigarettes (10 to 20 cigarettes)
CL Item
More Than 20 Cigarettes (More than 20 cigarettes)
Item Group
Section 3 - Alcohol Consumption
AlcoholLifetimeHistoryIndicator
Item
During your entire life, have you had at least 12 drinks of any kind of alcoholic beverage? ([this includes beer 1 bottle/can, wine 1 glass, and hard liquor 1 cocktail or 1 shot of liquor])
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
AlcoholUseLifetimeInd
Item
In any one year have you had at least 12 drinks of any kind of alcoholic beverage (this includes beer, wine, and hard liquor)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
AlcoholConsumptionPastYearIndicator
Item
In the last 12 months have you had at least 12 drinks of any kind of alcoholic beverage (this includes beer, wine, and hard liquor)
boolean
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus Property)
C0439234 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
C25609 (NCI Thesaurus Property-3)
C1444637 (UMLS 2011AA Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
On about how many days did you have at least one drink of alcohol (In the last 12 months when you drank alcohol, think about a typical month)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
CL.16
Code List
On about how many days did you have at least one drink of alcohol (In the last 12 months when you drank alcohol, think about a typical month)
CL Item
1 - 2 Days (1 - 2 days)
CL Item
3 - 5 Days (3 - 5 days)
CL Item
6 - 9 Days (6 - 9 days)
CL Item
10 - 19 Days (10 - 19 days)
CL Item
20 - 29 Days (20 - 29 days)
CL Item
Every Day (Every day)
Item
On the days when you drank, about how many drinks did you have on average
text
C2190 (NCI Thesaurus ObjectClass)
C0001962 (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)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.17
Code List
On the days when you drank, about how many drinks did you have on average
CL Item
Less Than 1 Drink Per Day (Less than 1 drink per day)
CL Item
1 - 2 Per Day (1 - 2 per day)
CL Item
3 - 5 Per Day (3 - 5 per day)
CL Item
6+ Per Day (6+ per day)
AlcoholDrinkUseWeekNumber
Item
How many drinks of any kind of alcoholic beverage have you had in the last week
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
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