ID
10037
Beschreibung
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
Stichworte
Versionen (3)
- 18.12.14 18.12.14 - Martin Dugas
- 20.03.15 20.03.15 - Martin Dugas
- 20.09.21 20.09.21 -
Hochgeladen am
20. März 2015
DOI
Für eine Beantragung loggen Sie sich ein.
Lizenz
Creative Commons BY-NC 3.0 Legacy
Modell Kommentare :
Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.
Itemgroup Kommentare für :
Item Kommentare für :
Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.
Breast Cancer (NCT00024102)
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.
Beschreibung
Patient characteristics
Alias
- UMLS CUI-1
- C0815172
Beschreibung
Othercancersorleukemia
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
How much does it interfere with your activities: Other cancers or leukemia (b.)
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschreibung
Arthritis,rheumatism,orotherconnectivetissuedisorders
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Glaucoma (c.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0017601
Beschreibung
Howmuchdoesitinterferewithyouractivities:Glaucoma
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschreibung
Emphysema or Chronic Bronchitis (d.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
HighBloodPressure
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0020538
Beschreibung
Howmuchdoesitinterferewithyouractivities:HighBloodPressure
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Heartdisease
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0018799
Beschreibung
Howmuchdoesitinterferewithyouractivities:Heartdisease
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschreibung
Circulationtroubleinarmsorlegs
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0728936
Beschreibung
Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschreibung
Diabetes (h.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0011849
Beschreibung
Howmuchdoesitinterferewithyouractivities:Diabetes
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Stomach or intestinal disorders (i.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Osteoporosis (j.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0029456
Beschreibung
Howmuchdoesitinterferewithyouractivities:Osteoporosis
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Chronic Liver or Kidney Disease (k.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Stroke (l.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0038454
Beschreibung
How much does it interfere with your activities: Stroke (m.)
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Depression (m.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0011581
Beschreibung
How much does it interfere with your activities: Depression
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Howisyoureyesight(withglassesorcontacts)?
Datentyp
text
Alias
- UMLS CUI-1
- C0042812
Beschreibung
Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
Datentyp
text
Alias
- UMLS CUI-1
- C0018767
Beschreibung
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschreibung
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
Datentyp
text
Beschreibung
Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)
Datentyp
text
Beschreibung
how much does this interfere with your activities? (mark one with an X)
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschreibung
Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?
Datentyp
text
Beschreibung
Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?
Datentyp
text
Beschreibung
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Datentyp
text
Beschreibung
Counseling
Beschreibung
Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0849496
Beschreibung
What type of counseling or treatment did you receive? (mark all that apply with an X)
Datentyp
text
Beschreibung
Other, specify (type of counseling or treatment received) (8c.)
Datentyp
text
Beschreibung
Check any of these services that you are still receiving (mark all that apply with an X)
Datentyp
text
Beschreibung
Other,specify(servicesthatyouarestillreceiving)
Datentyp
text
Beschreibung
Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0849496
Beschreibung
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Datentyp
text
Beschreibung
Other,specify(servicesthatyouarestillreceiving;follow-up)
Datentyp
text
Beschreibung
Medication
Alias
- UMLS CUI-1
- C0013227
Beschreibung
Medicine to treat nausea and/or vomiting
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
Medicine to treat diarrhea
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0003292
Beschreibung
Medicinetoreducefeelingverytired[fatigue]
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Medicinetoreduceswellinginhandsorfeet
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Medicineorcreamtotreatmouthsores
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Painmedicineforhandsorfeet
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
Other,specify
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)
Datentyp
text
Beschreibung
Arthritismedicine
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Arthritis medicine (b.)
Datentyp
text
Beschreibung
Prescriptionpainkiller
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Datentyp
text
Alias
- UMLS CUI-1
- C0002771
- UMLS CUI-2
- C0439603
Beschreibung
Over-thecounterpainkillers
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
Datentyp
text
Beschreibung
Highbloodpressuremedicine
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: High blood pressure medicine (e.)
Datentyp
text
Beschreibung
Pillstomakeyoulosewaterorsalt
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Pills to make you lose water or salt (f.)
Datentyp
text
Beschreibung
Digoxinpillsfortheheart
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Datentyp
text
Beschreibung
Nitroglycerinforchestpain
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Datentyp
text
Beschreibung
Bloodthinnermedicine
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Blood thinner medicine (anticoagulants)
Datentyp
text
Beschreibung
Medicinetoimprovecirculation
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Medicine to improve circulation (j.)
Datentyp
text
Beschreibung
Insulin injections for diabetes (j.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0199782
Beschreibung
If Taken, How Often: Insulin injections for diabetes (k.)
Datentyp
text
Beschreibung
Pillsfordiabetes
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Pills for diabetes (l.)
Datentyp
text
Beschreibung
Ulcermedicine
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Ulcer medicine (m.)
Datentyp
text
Beschreibung
Asthma medicines (m.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282556
Beschreibung
If Taken, How Often: Asthma medicines (n.)
Datentyp
text
Beschreibung
Seizuremedicines
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Seizure medicines (like Dilantin)
Datentyp
text
Beschreibung
Thyroidpills
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Thyroid pills (p.)
Datentyp
text
Beschreibung
Cortisonepillsorinjections
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0010137
Beschreibung
If Taken, How Often: Cortisone pills or injections (q.)
Datentyp
text
Beschreibung
Antibiotics (q.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0003232
Beschreibung
If Taken, How Often: Antibiotics (r.)
Datentyp
text
Beschreibung
Tranquilizersormedicineforyournerves
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0040614
Beschreibung
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Datentyp
text
Beschreibung
Prescriptionsleepingpills
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0599396
Beschreibung
If Taken, How Often: Prescription sleeping pills (t.)
Datentyp
text
Beschreibung
Over-the-counterpillstohelpyousleep
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Datentyp
text
Beschreibung
Hormones (male or female)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0019932
Beschreibung
If Taken, How Often: Hormones (v.)
Datentyp
text
Beschreibung
Allergy medicines (v.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282555
Beschreibung
If Taken, How Often: Allergy medicines (w.)
Datentyp
text
Beschreibung
Laxatives (w.)
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282090
Beschreibung
If Taken, How Often: Laxatives (x.)
Datentyp
text
Beschreibung
Eyedropsforglaucoma
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Eye drops for glaucoma (y.)
Datentyp
text
Beschreibung
Calciumtablets
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Calcium tablets (z.)
Datentyp
text
Beschreibung
Vitaminsand/orminerals
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Datentyp
text
Beschreibung
Herbalmedicines
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0242388
Beschreibung
If Taken, How Often: Herbal medicines (12.)
Datentyp
text
Beschreibung
Have you taken any other medicines in the past month?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1522602
Beschreibung
NameofMedicine
Datentyp
text
Beschreibung
If Taken, How Often?
Datentyp
text
Alias
- UMLS CUI-1
- C3476109
Ähnliche Modelle
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.
C1516238 (UMLS CUI-2)
C1516238 (UMLS CUI-2)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0332307 (UMLS CUI-1)
C0017601 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0020538 (UMLS CUI-1)
C0018799 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0728936 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0011849 (UMLS CUI-1)
C0029456 (UMLS CUI-1)
C0038454 (UMLS CUI-1)
C0011581 (UMLS CUI-1)
C0205170 (UMLS CUI-1)
C0205170 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C1298908 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0849496 (UMLS CUI-1)
C0849496 (UMLS CUI-1)
C0003292 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0439603 (UMLS CUI-2)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0199782 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0282556 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0010137 (UMLS CUI-1)
C0003232 (UMLS CUI-1)
C0040614 (UMLS CUI-1)
C0599396 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C0019932 (UMLS CUI-1)
C0282555 (UMLS CUI-1)
C0282090 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0242388 (UMLS CUI-1)
C1522602 (UMLS CUI-1)