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ID
10622
Beschrijving
CALGB: PHYSICAL PROBLEMS DUE TO CANCER TREATMENT FORM NCT00024102 Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CCBC1-A49F-3714-E034-080020C9C0E0
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- 26-08-12 26-08-12 -
- 22-05-15 22-05-15 -
- 03-06-15 03-06-15 -
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3 juni 2015
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Creative Commons BY-NC 3.0 Legacy
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CALGB: PHYSICAL PROBLEMS DUE TO CANCER TREATMENT FORM 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.
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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.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (M)
date
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient's Name
text
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (ADDITIONAL PHYSICAL PROBLEMS DUE TO CANCER TREATMENT [SIDE EFFECTS])
float
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
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
Item
Mouth sores
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
A Little (A Little)
CL Item
Quite A Bit (Quite a Bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very Much)
C91217 (NCI Thesaurus)
Item
Skin changes (such as redness or peeling) on hands or feet
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
A Little (A Little)
CL Item
Quite A Bit (Quite a Bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very Much)
C91217 (NCI Thesaurus)
Item
Swelling in hands or feet
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
A Little (A Little)
CL Item
Quite A Bit (Quite a Bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very Much)
C91217 (NCI Thesaurus)
Item
Pain in hands or feet (OVERALL QUALITY OF LIFE)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
A Little (A Little)
CL Item
Quite A Bit (Quite a Bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very Much)
C91217 (NCI Thesaurus)
whatnumberwouldyousaybestdescribesyourcurrentstatofhealthoverjustthepasttwoweeks?
Item
what number would you say best describes your current stat of health over just the past two weeks? (3. Imagine that a friend of yours is expected to live for 15 years with the same quality of live as you have now. Suppose treatment could restore your friend to full health, but would shorten his/her life.)
float
Atmost,howmuchtimewouldyouadviseyourfriendtogiveupoutof15yearsinordertoreturntofullhealth?
Item
At most, how much time would you advise your friend to give up out of 15 years in order to return to full health? (months)
float