ID

11500

Descripción

NCT00087178 NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C893003F-B432-7480-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C893003F-B432-7480-E034-0003BA12F5E7

Palabras clave

Versiones (3)
  1. 26/8/12 26/8/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 5/7/15 5/7/15 -
Subido en

5 de julio de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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NCT00087178 NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire

Inglés

(For all B-36 Patients)

1 formularios  
  1. StudyEvent: NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire
    1. (For all B-36 Patients)
Header
Descripción

Header

Patient Initials (Last, First Middle)
Descripción

Patient Initials

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
NSABP Patient ID
Descripción

Patient ID NSABP

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1513905
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C15818
Date Questionnaire Completed
Descripción

Date Questionnaire Completed

Date Questionnaire Completed (Month Day Year)
Descripción

QualityofLifeCompleteAssessmentDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property-2
C25367
Section A
Descripción

Section A

Have you had your uterus removed?
Descripción

UterusRemovedInd-3

Tipo de datos

text

Have you had both your ovaries removed?
Descripción

OvaryRemovedInd-3

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C12404
UMLS 2011AA ObjectClass
C0029939
NCI Thesaurus Property
C25650
UMLS 2011AA Property
C0849355
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
Descripción

MensesOccurrenceInd-3

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ObjectClass
C3232
UMLS 2011AA ObjectClass
C0025344
Section B
Descripción

Section B

When was your last menstrual period (or vaginal bleeding)? (Month Year)
Descripción

Firstdayoflastmenstrualperiod

Tipo de datos

text

Did your periods stop or become less frequent during the last 12 months?
Descripción

MensesEndOccurrenceInd-3

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ObjectClass
C3232
UMLS 2011AA ObjectClass
C0025344
NCI Thesaurus Property-2
C25496
UMLS 2011AA Property-2
C2746065
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
Descripción

HormoneReplacementTherapyAdministeredInd-3

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15599
UMLS 2011AA ObjectClass
C0282402
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
Descripción

HormoneTherapyContraceptionAdministeredInd-3

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15445
UMLS 2011AA ObjectClass
C0279025
NCI Thesaurus Property
C37932
UMLS 2011AA Property
C0700589
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
Ccrr Module For Nsabp Protocol B-36 Baseline Menstrual History Questionnaire
Descripción

Ccrr Module For Nsabp Protocol B-36 Baseline Menstrual History Questionnaire

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Similar models

(For all B-36 Patients)

1 formularios
  1. StudyEvent: NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire
    1. (For all B-36 Patients)
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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)
Item Group
Date Questionnaire Completed
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 A
Item
Have you had your uterus removed?
text
CL.1
Code List
Have you had your uterus removed?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you had both your ovaries removed?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12404 (NCI Thesaurus ObjectClass)
C0029939 (UMLS 2011AA ObjectClass)
C25650 (NCI Thesaurus Property)
C0849355 (UMLS 2011AA Property)
CL.2
Code List
Have you had both your ovaries removed?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C3232 (NCI Thesaurus ObjectClass)
C0025344 (UMLS 2011AA ObjectClass)
CL.3
Code List
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Section B
Firstdayoflastmenstrualperiod
Item
When was your last menstrual period (or vaginal bleeding)? (Month Year)
text
Item
Did your periods stop or become less frequent during the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C3232 (NCI Thesaurus ObjectClass)
C0025344 (UMLS 2011AA ObjectClass)
C25496 (NCI Thesaurus Property-2)
C2746065 (UMLS 2011AA Property-2)
CL.4
Code List
Did your periods stop or become less frequent during the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15599 (NCI Thesaurus ObjectClass)
C0282402 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.5
Code List
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
Item
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C37932 (NCI Thesaurus Property)
C0700589 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
CL.6
Code List
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unsure)
Item Group
Ccrr Module For Nsabp Protocol B-36 Baseline Menstrual History Questionnaire
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