ID
10037
Beskrivning
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
Länk
Nyckelord
Versioner (3)
- 2014-12-18 2014-12-18 - Martin Dugas
- 2015-03-20 2015-03-20 - Martin Dugas
- 2021-09-20 2021-09-20 -
Uppladdad den
20 mars 2015
DOI
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Licens
Creative Commons BY-NC 3.0 Legacy
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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.
Beskrivning
Patient characteristics
Alias
- UMLS CUI-1
- C0815172
Beskrivning
Othercancersorleukemia
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beskrivning
How much does it interfere with your activities: Other cancers or leukemia (b.)
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beskrivning
Arthritis,rheumatism,orotherconnectivetissuedisorders
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beskrivning
Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Glaucoma (c.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0017601
Beskrivning
Howmuchdoesitinterferewithyouractivities:Glaucoma
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beskrivning
Emphysema or Chronic Bronchitis (d.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beskrivning
Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
HighBloodPressure
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0020538
Beskrivning
Howmuchdoesitinterferewithyouractivities:HighBloodPressure
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Heartdisease
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0018799
Beskrivning
Howmuchdoesitinterferewithyouractivities:Heartdisease
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beskrivning
Circulationtroubleinarmsorlegs
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0728936
Beskrivning
Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beskrivning
Diabetes (h.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0011849
Beskrivning
Howmuchdoesitinterferewithyouractivities:Diabetes
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Stomach or intestinal disorders (i.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beskrivning
Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Osteoporosis (j.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0029456
Beskrivning
Howmuchdoesitinterferewithyouractivities:Osteoporosis
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Chronic Liver or Kidney Disease (k.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beskrivning
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Stroke (l.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0038454
Beskrivning
How much does it interfere with your activities: Stroke (m.)
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Depression (m.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0011581
Beskrivning
How much does it interfere with your activities: Depression
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Howisyoureyesight(withglassesorcontacts)?
Datatyp
text
Alias
- UMLS CUI-1
- C0042812
Beskrivning
Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
Datatyp
text
Alias
- UMLS CUI-1
- C0018767
Beskrivning
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beskrivning
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
Datatyp
text
Beskrivning
Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)
Datatyp
text
Beskrivning
how much does this interfere with your activities? (mark one with an X)
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beskrivning
Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?
Datatyp
text
Beskrivning
Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?
Datatyp
text
Beskrivning
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Datatyp
text
Beskrivning
Counseling
Beskrivning
Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0849496
Beskrivning
What type of counseling or treatment did you receive? (mark all that apply with an X)
Datatyp
text
Beskrivning
Other, specify (type of counseling or treatment received) (8c.)
Datatyp
text
Beskrivning
Check any of these services that you are still receiving (mark all that apply with an X)
Datatyp
text
Beskrivning
Other,specify(servicesthatyouarestillreceiving)
Datatyp
text
Beskrivning
Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0849496
Beskrivning
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Datatyp
text
Beskrivning
Other,specify(servicesthatyouarestillreceiving;follow-up)
Datatyp
text
Beskrivning
Medication
Alias
- UMLS CUI-1
- C0013227
Beskrivning
Medicine to treat nausea and/or vomiting
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beskrivning
Medicine to treat diarrhea
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0003292
Beskrivning
Medicinetoreducefeelingverytired[fatigue]
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
Medicinetoreduceswellinginhandsorfeet
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
Medicineorcreamtotreatmouthsores
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
Painmedicineforhandsorfeet
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beskrivning
Other,specify
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)
Datatyp
text
Beskrivning
Arthritismedicine
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Arthritis medicine (b.)
Datatyp
text
Beskrivning
Prescriptionpainkiller
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Datatyp
text
Alias
- UMLS CUI-1
- C0002771
- UMLS CUI-2
- C0439603
Beskrivning
Over-thecounterpainkillers
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
Datatyp
text
Beskrivning
Highbloodpressuremedicine
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: High blood pressure medicine (e.)
Datatyp
text
Beskrivning
Pillstomakeyoulosewaterorsalt
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Pills to make you lose water or salt (f.)
Datatyp
text
Beskrivning
Digoxinpillsfortheheart
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Datatyp
text
Beskrivning
Nitroglycerinforchestpain
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Datatyp
text
Beskrivning
Bloodthinnermedicine
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Blood thinner medicine (anticoagulants)
Datatyp
text
Beskrivning
Medicinetoimprovecirculation
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Medicine to improve circulation (j.)
Datatyp
text
Beskrivning
Insulin injections for diabetes (j.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0199782
Beskrivning
If Taken, How Often: Insulin injections for diabetes (k.)
Datatyp
text
Beskrivning
Pillsfordiabetes
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Pills for diabetes (l.)
Datatyp
text
Beskrivning
Ulcermedicine
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Ulcer medicine (m.)
Datatyp
text
Beskrivning
Asthma medicines (m.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282556
Beskrivning
If Taken, How Often: Asthma medicines (n.)
Datatyp
text
Beskrivning
Seizuremedicines
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Seizure medicines (like Dilantin)
Datatyp
text
Beskrivning
Thyroidpills
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Thyroid pills (p.)
Datatyp
text
Beskrivning
Cortisonepillsorinjections
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0010137
Beskrivning
If Taken, How Often: Cortisone pills or injections (q.)
Datatyp
text
Beskrivning
Antibiotics (q.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0003232
Beskrivning
If Taken, How Often: Antibiotics (r.)
Datatyp
text
Beskrivning
Tranquilizersormedicineforyournerves
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0040614
Beskrivning
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Datatyp
text
Beskrivning
Prescriptionsleepingpills
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0599396
Beskrivning
If Taken, How Often: Prescription sleeping pills (t.)
Datatyp
text
Beskrivning
Over-the-counterpillstohelpyousleep
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Datatyp
text
Beskrivning
Hormones (male or female)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0019932
Beskrivning
If Taken, How Often: Hormones (v.)
Datatyp
text
Beskrivning
Allergy medicines (v.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282555
Beskrivning
If Taken, How Often: Allergy medicines (w.)
Datatyp
text
Beskrivning
Laxatives (w.)
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282090
Beskrivning
If Taken, How Often: Laxatives (x.)
Datatyp
text
Beskrivning
Eyedropsforglaucoma
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Eye drops for glaucoma (y.)
Datatyp
text
Beskrivning
Calciumtablets
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Calcium tablets (z.)
Datatyp
text
Beskrivning
Vitaminsand/orminerals
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Datatyp
text
Beskrivning
Herbalmedicines
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0242388
Beskrivning
If Taken, How Often: Herbal medicines (12.)
Datatyp
text
Beskrivning
Have you taken any other medicines in the past month?
Datatyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1522602
Beskrivning
NameofMedicine
Datatyp
text
Beskrivning
If Taken, How Often?
Datatyp
text
Alias
- UMLS CUI-1
- C3476109
Similar models
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)