ID

10037

Description

Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer NCT00024102 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Keywords

Versions (3)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 3/20/15 3/20/15 - Martin Dugas
  3. 9/20/21 9/20/21 -
Uploaded on

March 20, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer (NCT00024102)

English

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 forms  
Header
Description

Header

CALGB Form
Description

CALGB Form

Data type

text

Alias
UMLS CUI-1
C3262252
UMLS CUI-2
C1516238
CALGB Study No
Description

CALGBStudyNo

Data type

text

Alias
UMLS CUI-1
C3274381
UMLS CUI-2
C1516238
CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (Medicine)
Description

DateCompleted

Data type

date

Amended data?
Description

Amended data?

Data type

boolean

Alias
UMLS CUI-1
C0680532
Patient's Name
Description

Patient'sName

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Data type

text

Responsible CRA
Description

ResponsibleCRA

Data type

text

Assessment Number (1. Your General Health)
Description

AssessmentNumber

Data type

float

Patient characteristics
Description

Patient characteristics

Alias
UMLS CUI-1
C0815172
Other cancers or leukemia
Description

Othercancersorleukemia

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Other cancers or leukemia (b.)
Description

How much does it interfere with your activities: Other cancers or leukemia (b.)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Arthritis, rheumatism, or other connective tissue disorders (b.)
Description

Arthritis,rheumatism,orotherconnectivetissuedisorders

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
Description

Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
Glaucoma (c.)
Description

Glaucoma (c.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0017601
How much does it interfere with your activities: Glaucoma (d.)
Description

Howmuchdoesitinterferewithyouractivities:Glaucoma

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Emphysema or Chronic Bronchitis (d.)
Description

Emphysema or Chronic Bronchitis (d.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
Description

Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
High Blood Pressure (e.)
Description

HighBloodPressure

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0020538
How much does it interfere with your activities: High Blood Pressure (f.)
Description

Howmuchdoesitinterferewithyouractivities:HighBloodPressure

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
Heart disease (f.)
Description

Heartdisease

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0018799
How much does it interfere with your activities: Heart disease (g.)
Description

Howmuchdoesitinterferewithyouractivities:Heartdisease

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Circulation trouble in arms or legs (g.)
Description

Circulationtroubleinarmsorlegs

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0728936
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
Description

Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Diabetes (h.)
Description

Diabetes (h.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0011849
How much does it interfere with your activities: Diabetes (i.)
Description

Howmuchdoesitinterferewithyouractivities:Diabetes

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
Stomach or intestinal disorders (i.)
Description

Stomach or intestinal disorders (i.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
Description

Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
Osteoporosis (j.)
Description

Osteoporosis (j.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0029456
How much does it interfere with your activities: Osteoporosis (k.)
Description

Howmuchdoesitinterferewithyouractivities:Osteoporosis

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
Chronic Liver or Kidney Disease (k.)
Description

Chronic Liver or Kidney Disease (k.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Description

How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
Stroke (l.)
Description

Stroke (l.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0038454
How much does it interfere with your activities: Stroke (m.)
Description

How much does it interfere with your activities: Stroke (m.)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
Depression (m.)
Description

Depression (m.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0011581
How much does it interfere with your activities: Depression
Description

How much does it interfere with your activities: Depression

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
How is your eyesight (with glasses or contacts)? (mark one with an X)
Description

Howisyoureyesight(withglassesorcontacts)?

Data type

text

Alias
UMLS CUI-1
C0042812
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
Description

Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
Description

How is your hearing (with a hearing aid, if needed)? (mark one with an X)

Data type

text

Alias
UMLS CUI-1
C0018767
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Description

If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
Description

Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?

Data type

text

Yes, specify (other physical problems or illnesses at the present time that seriously affect your health) (If Yes)
Description

Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)

Data type

text

how much does this interfere with your activities? (mark one with an X)
Description

how much does this interfere with your activities? (mark one with an X)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
Description

Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?

Data type

text

During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
Description

Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?

Data type

text

How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Description

How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)

Data type

text

Counseling
Description

Counseling

Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
Description

Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0849496
What type of counseling or treatment did you receive? (mark all that apply with an X)
Description

What type of counseling or treatment did you receive? (mark all that apply with an X)

Data type

text

Other, specify (type of counseling or treatment received) (8c.)
Description

Other, specify (type of counseling or treatment received) (8c.)

Data type

text

Check any of these services that you are still receiving (mark all that apply with an X)
Description

Check any of these services that you are still receiving (mark all that apply with an X)

Data type

text

Other, specify (services that you are still receiving) (Only For ALL FOLLOW-UP INTERVIEWS: Questions 9-10)
Description

Other,specify(servicesthatyouarestillreceiving)

Data type

text

Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
Description

Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0849496
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Description

What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)

Data type

text

Other, specify (services that you are still receiving; follow-up)
Description

Other,specify(servicesthatyouarestillreceiving;follow-up)

Data type

text

Medication
Description

Medication

Alias
UMLS CUI-1
C0013227
Medicine to treat nausea and/or vomiting
Description

Medicine to treat nausea and/or vomiting

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
Medicine to treat diarrhea
Description

Medicine to treat diarrhea

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0003292
Medicine to reduce feeling very tired [fatigue]
Description

Medicinetoreducefeelingverytired[fatigue]

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine to reduce swelling in hands or feet
Description

Medicinetoreduceswellinginhandsorfeet

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine or cream to treat mouth sores
Description

Medicineorcreamtotreatmouthsores

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Pain medicine for hands or feet
Description

Painmedicineforhandsorfeet

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Description

Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
Other, specify
Description

Other,specify

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Other, specify (medication to treat any physical problems you have had from your cancer treatment)
Description

Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)

Data type

text

Arthritis medicine (If Taken, How Often?)
Description

Arthritismedicine

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Arthritis medicine (b.)
Description

If Taken, How Often: Arthritis medicine (b.)

Data type

text

Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Description

Prescriptionpainkiller

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Description

If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)

Data type

text

Alias
UMLS CUI-1
C0002771
UMLS CUI-2
C0439603
Over-the counter pain killers (c.)
Description

Over-thecounterpainkillers

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
Description

If Taken, How Often: Over-the counter pain killers (other than for arthritis)

Data type

text

High blood pressure medicine (d.)
Description

Highbloodpressuremedicine

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: High blood pressure medicine (e.)
Description

If Taken, How Often: High blood pressure medicine (e.)

Data type

text

Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
Description

Pillstomakeyoulosewaterorsalt

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Pills to make you lose water or salt (f.)
Description

If Taken, How Often: Pills to make you lose water or salt (f.)

Data type

text

Digoxin pills for the heart (Lanoxin)
Description

Digoxinpillsfortheheart

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Description

If Taken, How Often: Digoxin pills for the heart (Lanoxin)

Data type

text

Nitroglycerin for chest pain (tablets or patches)
Description

Nitroglycerinforchestpain

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Description

If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)

Data type

text

Blood thinner medicine (anticoagulants)
Description

Bloodthinnermedicine

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Blood thinner medicine (anticoagulants)
Description

If Taken, How Often: Blood thinner medicine (anticoagulants)

Data type

text

Medicine to improve circulation (i.)
Description

Medicinetoimprovecirculation

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Medicine to improve circulation (j.)
Description

If Taken, How Often: Medicine to improve circulation (j.)

Data type

text

Insulin injections for diabetes (j.)
Description

Insulin injections for diabetes (j.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0199782
If Taken, How Often: Insulin injections for diabetes (k.)
Description

If Taken, How Often: Insulin injections for diabetes (k.)

Data type

text

Pills for diabetes (k.)
Description

Pillsfordiabetes

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Pills for diabetes (l.)
Description

If Taken, How Often: Pills for diabetes (l.)

Data type

text

Ulcer medicine (l.)
Description

Ulcermedicine

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Ulcer medicine (m.)
Description

If Taken, How Often: Ulcer medicine (m.)

Data type

text

Asthma medicines (m.)
Description

Asthma medicines (m.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282556
If Taken, How Often: Asthma medicines (n.)
Description

If Taken, How Often: Asthma medicines (n.)

Data type

text

Seizure medicines (like Dilantin)
Description

Seizuremedicines

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Seizure medicines (like Dilantin)
Description

If Taken, How Often: Seizure medicines (like Dilantin)

Data type

text

Thyroid pills (If Taken, How Often?)
Description

Thyroidpills

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Thyroid pills (p.)
Description

If Taken, How Often: Thyroid pills (p.)

Data type

text

Cortisone pills or injections (p.)
Description

Cortisonepillsorinjections

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0010137
If Taken, How Often: Cortisone pills or injections (q.)
Description

If Taken, How Often: Cortisone pills or injections (q.)

Data type

text

Antibiotics (q.)
Description

Antibiotics (q.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0003232
If Taken, How Often: Antibiotics (r.)
Description

If Taken, How Often: Antibiotics (r.)

Data type

text

Tranquilizers or medicine for your nerves (r.)
Description

Tranquilizersormedicineforyournerves

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0040614
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Description

If Taken, How Often: Tranquilizers or medicine for your nerves (s.)

Data type

text

Prescription sleeping pills (s.)
Description

Prescriptionsleepingpills

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0599396
If Taken, How Often: Prescription sleeping pills (t.)
Description

If Taken, How Often: Prescription sleeping pills (t.)

Data type

text

Over-the-counter pills to help you sleep (t.)
Description

Over-the-counterpillstohelpyousleep

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Description

If Taken, How Often: Over-the-counter pills to help you sleep (u.)

Data type

text

Hormones (male or female)
Description

Hormones (male or female)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0019932
If Taken, How Often: Hormones (v.)
Description

If Taken, How Often: Hormones (v.)

Data type

text

Allergy medicines (v.)
Description

Allergy medicines (v.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282555
If Taken, How Often: Allergy medicines (w.)
Description

If Taken, How Often: Allergy medicines (w.)

Data type

text

Laxatives (w.)
Description

Laxatives (w.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282090
If Taken, How Often: Laxatives (x.)
Description

If Taken, How Often: Laxatives (x.)

Data type

text

Eye drops for glaucoma (x.)
Description

Eyedropsforglaucoma

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Eye drops for glaucoma (y.)
Description

If Taken, How Often: Eye drops for glaucoma (y.)

Data type

text

Calcium tablets (y.)
Description

Calciumtablets

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Calcium tablets (z.)
Description

If Taken, How Often: Calcium tablets (z.)

Data type

text

Vitamins and/or minerals (other than calcium)
Description

Vitaminsand/orminerals

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Description

If Taken, How Often: Vitamins and/or minerals (other than calcium)

Data type

text

Herbal medicines (aa.)
Description

Herbalmedicines

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0242388
If Taken, How Often: Herbal medicines (12.)
Description

If Taken, How Often: Herbal medicines (12.)

Data type

text

Have you taken any other medicines in the past month?
Description

Have you taken any other medicines in the past month?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1522602
Name of Medicine
Description

NameofMedicine

Data type

text

If Taken, How Often?
Description

If Taken, How Often?

Data type

text

Alias
UMLS CUI-1
C3476109
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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGBForm
Item
CALGB Form
text
C3262252 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGBStudyNo
Item
CALGB Study No
text
C3274381 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Amendeddata
Item
Amended data?
boolean
C0680532 (UMLS CUI-1)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1. Your General Health)
float
Item Group
C0815172 (UMLS CUI-1)
Other cancers or leukemia
Item
Other cancers or leukemia
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Other cancers or leukemia (b.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
How much does it interfere with your activities: Other cancers or leukemia (b.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Arthritis or rheumatism
Item
Arthritis, rheumatism, or other connective tissue disorders (b.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Glaucoma
Item
Glaucoma (c.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0017601 (UMLS CUI-1)
Item
How much does it interfere with your activities: Glaucoma (d.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
How much does it interfere with your activities: Glaucoma (d.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Emphysema or ChronicBronchitis
Item
Emphysema or Chronic Bronchitis (d.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
High Blood Pressure
Item
High Blood Pressure (e.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0020538 (UMLS CUI-1)
Item
How much does it interfere with your activities: High Blood Pressure (f.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: High Blood Pressure (f.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Heartdisease
Item
Heart disease (f.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0018799 (UMLS CUI-1)
Item
How much does it interfere with your activities: Heart disease (g.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
How much does it interfere with your activities: Heart disease (g.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Circulation disorder
Item
Circulation trouble in arms or legs (g.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0728936 (UMLS CUI-1)
Item
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Diabetes
Item
Diabetes (h.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0011849 (UMLS CUI-1)
Item
How much does it interfere with your activities: Diabetes (i.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Diabetes (i.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Stomach or intestinal disorders
Item
Stomach or intestinal disorders (i.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Osteoporosis
Item
Osteoporosis (j.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0029456 (UMLS CUI-1)
Item
How much does it interfere with your activities: Osteoporosis (k.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Osteoporosis (k.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Chronic Liver or Kidney Disease
Item
Chronic Liver or Kidney Disease (k.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Stroke
Item
Stroke (l.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0038454 (UMLS CUI-1)
Item
How much does it interfere with your activities: Stroke (m.)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Stroke (m.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Depression
Item
Depression (m.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0011581 (UMLS CUI-1)
Item
How much does it interfere with your activities: Depression
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Depression
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
How is your eyesight (with glasses or contacts)? (mark one with an X)
text
C0042812 (UMLS CUI-1)
CL.28
Code List
How is your eyesight (with glasses or contacts)? (mark one with an X)
CL Item
Excellent (Excellent)
C1961136 (UMLS CUI-1)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
C0205170 (UMLS CUI-1)
CL Item
Fair (Fair)
C2911689 (UMLS CUI-1)
CL Item
Poor (Poor)
C2700379 (UMLS CUI-1)
CL Item
Totally Blind (Totally blind)
C0456909 (UMLS CUI-1)
Item
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
text
C0018767 (UMLS CUI-1)
CL.30
Code List
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
CL Item
Excellent (Excellent)
C1961136 (UMLS CUI-1)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
C0205170 (UMLS CUI-1)
CL Item
Fair (Fair)
C2911689 (UMLS CUI-1)
CL Item
Poor (Poor)
C2700379 (UMLS CUI-1)
CL Item
Totally Deaf (Totally deaf)
C1547302 (UMLS CUI-1)
Item
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
CL.3
Code List
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
text
CL.32
Code List
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Specify (Yes, specify)
Other physical problems or illnesses
Item
Yes, specify (other physical problems or illnesses at the present time that seriously affect your health) (If Yes)
text
Item
how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
CL.3
Code List
how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
text
CL.34
Code List
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 To 2 (1 to 2)
CL Item
3 To 5 (3 to 5)
CL Item
6 To 9 (6 to 9)
CL Item
10 To 14 (10 to 14)
CL Item
15 Or More (15 or more)
CL Item
Don't Know (Don't know)
Item
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
text
CL.35
Code List
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
A Week Or Less (A week or less)
CL Item
More Than A Week, But Less Than A Month (More than a week, but less than a month)
CL Item
One To Two Months (One to two months)
CL Item
Three Months (Three months)
Item
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
text
CL.36
Code List
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 To 2 (1 to 2)
CL Item
3 To 5 (3 to 5)
CL Item
6 To 9 (6 to 9)
CL Item
10 To 14 (10 to 14)
CL Item
15 Or More (15 or more)
CL Item
Don't Know (Don't know)
Item Group
problem related counselling
Item
Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0849496 (UMLS CUI-1)
Item
What type of counseling or treatment did you receive? (mark all that apply with an X)
text
CL.38
Code List
What type of counseling or treatment did you receive? (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other, specify
Item
Other, specify (type of counseling or treatment received) (8c.)
text
Item
Check any of these services that you are still receiving (mark all that apply with an X)
text
CL.38
Code List
Check any of these services that you are still receiving (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other,specify(servicesthatyouarestillreceiving)
Item
Other, specify (services that you are still receiving) (Only For ALL FOLLOW-UP INTERVIEWS: Questions 9-10)
text
problem related counselling
Item
Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0849496 (UMLS CUI-1)
Item
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
text
CL.38
Code List
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other services
Item
Other, specify (services that you are still receiving; follow-up)
text
Item Group
C0013227 (UMLS CUI-1)
Medicine to treat nausea and/or vomiting
Item
Medicine to treat nausea and/or vomiting
boolean
C25180 (NCI Thesaurus ValueDomain)
Medicine to treat diarrhea
Item
Medicine to treat diarrhea
boolean
C25180 (NCI Thesaurus ValueDomain)
C0003292 (UMLS CUI-1)
Medicinetoreducefeelingverytired[fatigue]
Item
Medicine to reduce feeling very tired [fatigue]
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medicinetoreduceswellinginhandsorfeet
Item
Medicine to reduce swelling in hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medicineorcreamtotreatmouthsores
Item
Medicine or cream to treat mouth sores
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Painmedicineforhandsorfeet
Item
Pain medicine for hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medication regarding skin changes
Item
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
Other,specify
Item
Other, specify
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Other medication
Item
Other, specify (medication to treat any physical problems you have had from your cancer treatment)
text
Arthritismedicine
Item
Arthritis medicine (If Taken, How Often?)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Arthritis medicine (b.)
text
CL.80
Code List
If Taken, How Often: Arthritis medicine (b.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Prescriptionpainkiller
Item
Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
text
C0002771 (UMLS CUI-1)
C0439603 (UMLS CUI-2)
CL.80
Code List
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Over-thecounterpainkillers
Item
Over-the counter pain killers (c.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
text
CL.80
Code List
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Highbloodpressuremedicine
Item
High blood pressure medicine (d.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: High blood pressure medicine (e.)
text
CL.80
Code List
If Taken, How Often: High blood pressure medicine (e.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Pillstomakeyoulosewaterorsalt
Item
Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Pills to make you lose water or salt (f.)
text
CL.80
Code List
If Taken, How Often: Pills to make you lose water or salt (f.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Digoxinpillsfortheheart
Item
Digoxin pills for the heart (Lanoxin)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
text
CL.80
Code List
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Nitroglycerinforchestpain
Item
Nitroglycerin for chest pain (tablets or patches)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
text
CL.80
Code List
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Bloodthinnermedicine
Item
Blood thinner medicine (anticoagulants)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Blood thinner medicine (anticoagulants)
text
CL.80
Code List
If Taken, How Often: Blood thinner medicine (anticoagulants)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Medicinetoimprovecirculation
Item
Medicine to improve circulation (i.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Medicine to improve circulation (j.)
text
CL.80
Code List
If Taken, How Often: Medicine to improve circulation (j.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Insulin injections for diabetes
Item
Insulin injections for diabetes (j.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0199782 (UMLS CUI-1)
Item
If Taken, How Often: Insulin injections for diabetes (k.)
text
CL.80
Code List
If Taken, How Often: Insulin injections for diabetes (k.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Pillsfordiabetes
Item
Pills for diabetes (k.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Pills for diabetes (l.)
text
CL.80
Code List
If Taken, How Often: Pills for diabetes (l.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Ulcermedicine
Item
Ulcer medicine (l.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Ulcer medicine (m.)
text
CL.80
Code List
If Taken, How Often: Ulcer medicine (m.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Asthma medicines
Item
Asthma medicines (m.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282556 (UMLS CUI-1)
Item
If Taken, How Often: Asthma medicines (n.)
text
CL.80
Code List
If Taken, How Often: Asthma medicines (n.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Seizuremedicines
Item
Seizure medicines (like Dilantin)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Seizure medicines (like Dilantin)
text
CL.80
Code List
If Taken, How Often: Seizure medicines (like Dilantin)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Thyroidpills
Item
Thyroid pills (If Taken, How Often?)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Thyroid pills (p.)
text
CL.80
Code List
If Taken, How Often: Thyroid pills (p.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Cortisone
Item
Cortisone pills or injections (p.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0010137 (UMLS CUI-1)
Item
If Taken, How Often: Cortisone pills or injections (q.)
text
CL.80
Code List
If Taken, How Often: Cortisone pills or injections (q.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Antibiotics
Item
Antibiotics (q.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0003232 (UMLS CUI-1)
Item
If Taken, How Often: Antibiotics (r.)
text
CL.80
Code List
If Taken, How Often: Antibiotics (r.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Tranquilizer
Item
Tranquilizers or medicine for your nerves (r.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0040614 (UMLS CUI-1)
Item
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
text
CL.80
Code List
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Sleeping pills
Item
Prescription sleeping pills (s.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0599396 (UMLS CUI-1)
Item
If Taken, How Often: Prescription sleeping pills (t.)
text
CL.80
Code List
If Taken, How Often: Prescription sleeping pills (t.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Over-the-counterpillstohelpyousleep
Item
Over-the-counter pills to help you sleep (t.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
text
CL.80
Code List
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Hormones
Item
Hormones (male or female)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0019932 (UMLS CUI-1)
Item
If Taken, How Often: Hormones (v.)
text
CL.80
Code List
If Taken, How Often: Hormones (v.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Allergy medicines
Item
Allergy medicines (v.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282555 (UMLS CUI-1)
Item
If Taken, How Often: Allergy medicines (w.)
text
CL.80
Code List
If Taken, How Often: Allergy medicines (w.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Laxatives
Item
Laxatives (w.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282090 (UMLS CUI-1)
Item
If Taken, How Often: Laxatives (x.)
text
CL.80
Code List
If Taken, How Often: Laxatives (x.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Eyedropsforglaucoma
Item
Eye drops for glaucoma (x.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Eye drops for glaucoma (y.)
text
CL.80
Code List
If Taken, How Often: Eye drops for glaucoma (y.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Calciumtablets
Item
Calcium tablets (y.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Calcium tablets (z.)
text
CL.80
Code List
If Taken, How Often: Calcium tablets (z.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Vitaminsand/orminerals
Item
Vitamins and/or minerals (other than calcium)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Vitamins and/or minerals (other than calcium)
text
CL.80
Code List
If Taken, How Often: Vitamins and/or minerals (other than calcium)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Herbal medicine
Item
Herbal medicines (aa.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0242388 (UMLS CUI-1)
Item
If Taken, How Often: Herbal medicines (12.)
text
CL.80
Code List
If Taken, How Often: Herbal medicines (12.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
other medication past month
Item
Have you taken any other medicines in the past month?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS CUI-1)
NameofMedicine
Item
Name of Medicine
text
Item
If Taken, How Often?
text
C3476109 (UMLS CUI-1)
CL.80
Code List
If Taken, How Often?
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
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