ID

11795

Descrizione

RTOG 0825 Phase III GBM Initial Evaluation Form (I1) Temozolomide and Radiation Therapy With or Without Bevacizumab in Treating Patients With Newly Diagnosed Glioblastoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5AE2A23C-8AD1-6A8B-E044-0003BA3F9857

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5AE2A23C-8AD1-6A8B-E044-0003BA3F9857

Keywords

  1. 26/08/12 26/08/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
  3. 04/08/15 04/08/15 - Martin Dugas
Caricato su

4 agosto 2015

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0 Legacy

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RTOG 0825 Phase III GBM Initial Evaluation Form (I1)

INSTRUCTIONS: Submit this form at protocol entry. Dates are recorded as mm-dd-yyyy unless otherwise specified

Module 1
Descrizione

Module 1

RTOG Study No.
Descrizione

Protocol ID RTOG

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
RTOG Case #
Descrizione

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C19778
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C49152
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1514695
UMLS CUI-2
C0600091
Institution Name
Descrizione

Institution Name

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Institution No.
Descrizione

Institution Number

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Patient Initials
Descrizione

Patient Initials

Tipo di dati

text

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

Trial subject ID RTOG

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Amended Data (INSTRUCTIONS: Complete form on web to unblind the protocol treatment arm)
Descrizione

Data amended

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Assessment
Descrizione

Assessment

Age
Descrizione

Age

Tipo di dati

integer

Unità di misura
  • years
Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C29848
NCI Thesaurus ValueDomain-2
C25463
NCI Thesaurus Property
C25150
UMLS CUI-1
C0001779
years
Karnofsky Performance Status
Descrizione

Karnofsky Performance Status

Tipo di dati

text

Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C20641
NCI Thesaurus ValueDomain
C25338
UMLS CUI-1
C0206065
Neurologic function
Descrizione

NeurologicalFunctionStatus

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25262
UMLS 2011AA ObjectClass
C0205494
NCI Thesaurus ObjectClass-2
C25518
UMLS 2011AA ObjectClass-2
C0542341
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Disease Information
Descrizione

Disease Information

Initial Diagnosis Date (OF GBM/GLIOSARCOMA MM DD YYYY)
Descrizione

CancerInitialDiagnosisDate

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property-2
C15220
UMLS 2011AA Property-2
C0011900
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
Extent of Resection
Descrizione

BrainMalignantNeoplasmExtentSurgicalResectionType

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C12439
UMLS 2011AA ObjectClass
C0006104
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus Property
C25698
NCI Thesaurus Property-2
C15232
UMLS 2011AA Property
C0728940
NCI Thesaurus Property-3
C25332
UMLS 2011AA Property-2
C0439792
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Other specify
Descrizione

BrainLesionSiteSpecify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass-2
C12439
UMLS 2011AA ObjectClass-2
C0006104
Date of Resection (MM DD YYYY)
Descrizione

PatientSurgicalResectionDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25698
NCI Thesaurus Property-2
C15232
UMLS 2011AA Property
C0728940
Central pathology confirmed GBM/gliosarcoma
Descrizione

AgreementCentralPathologyReviewGlioblastomaGliosarcomaPerformedInd-2

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C71684
UMLS 2011AA ObjectClass
C2347585
NCI Thesaurus ObjectClass-2
C25369
UMLS 2011AA ObjectClass-2
C0680240
NCI Thesaurus Property
C3058
UMLS 2011AA Property
C0017636
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
NCI Thesaurus Property-3
C3796
UMLS 2011AA Property-3
C0206726
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Sufficient tissue for MGMT/molecular profile analysis
Descrizione

LaboratoryConditionO-6-Methylguanine-DNAMethyltransferaseSpecimenType

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C37984
UMLS 2011AA ObjectClass
C0022877
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property-2
C25457
UMLS 2011AA Property-2
C0348080
NCI Thesaurus Property-3
C17315
UMLS 2011AA Property-3
C0069197
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Pre-study Scans
Descrizione

Pre-study Scans

Image date (MM DD YYYY)
Descrizione

DiagnosticImagingProcedureDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
NCI Thesaurus Property
C25218
UMLS 2011AA Property
C1948041
Assessment Type
Descrizione

Evaluation method

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C2911685
NCI Thesaurus ObjectClass
C20989
NCI Thesaurus Property
C16847
Other Specify
Descrizione

Evaluation method, specify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS CUI-1
C2911685
NCI Thesaurus ObjectClass
C20989
UMLS CUI-2
C1521902
NCI Thesaurus Property
C16847
Dimension 1 (mm)
Descrizione

TumorLargestDimensionMeasurement

Tipo di dati

float

Unità di misura
  • cm
Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25550
UMLS 2011AA Property
C0443228
NCI Thesaurus Property-2
C25483
UMLS 2011AA Property-2
C0439534
cm
Dimension 2 (mm)
Descrizione

TumorSecondDimensionMeasurement

Tipo di dati

float

Unità di misura
  • cm
Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25666
UMLS 2011AA Property
C0205436
NCI Thesaurus Property-2
C25483
UMLS 2011AA Property-2
C0439534
cm
Pre-study Scans
Descrizione

Pre-study Scans

Image date (MM DD YYYY)
Descrizione

DiagnosticImagingProcedureDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
NCI Thesaurus Property
C25218
UMLS 2011AA Property
C1948041
Assessment Type
Descrizione

Evaluation method

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C2911685
NCI Thesaurus ObjectClass
C20989
NCI Thesaurus Property
C16847
Other Specify
Descrizione

Evaluation method, specify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS CUI-1
C2911685
NCI Thesaurus ObjectClass
C20989
UMLS CUI-2
C1521902
NCI Thesaurus Property
C16847
Dimension 1 (mm)
Descrizione

TumorLargestDimensionMeasurement

Tipo di dati

float

Unità di misura
  • cm
Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25550
UMLS 2011AA Property
C0443228
NCI Thesaurus Property-2
C25483
UMLS 2011AA Property-2
C0439534
cm
Dimension 2 (mm)
Descrizione

TumorSecondDimensionMeasurement

Tipo di dati

float

Unità di misura
  • cm
Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25666
UMLS 2011AA Property
C0205436
NCI Thesaurus Property-2
C25483
UMLS 2011AA Property-2
C0439534
cm
Location Of Primary
Descrizione

Location Of Primary

Site of Lesion
Descrizione

BrainLesionSite

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass-2
C12439
UMLS 2011AA ObjectClass-2
C0006104
Other specify
Descrizione

BrainLesionSiteSpecify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass-2
C12439
UMLS 2011AA ObjectClass-2
C0006104
Primary Tumor Laterality
Descrizione

PrimaryTumorLateralityType

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass-2
C25251
UMLS 2011AA ObjectClass-2
C0205225
NCI Thesaurus Property
C25185
UMLS 2011AA Property
C0332304
Baseline Lab Values (hematologic)
Descrizione

Baseline Lab Values (hematologic)

ANC
Descrizione

ANC

Tipo di dati

float

Unità di misura
  • /ul
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C12533
NCI Thesaurus Property-2
C20200
NCI Thesaurus ValueDomain
C25304
NCI Thesaurus ValueDomain-2
C25712
UMLS CUI-1
C0948762
/ul
Date of ANC
Descrizione

LaboratoryProcedureNeutrophilResultDate

Tipo di dati

date

Unità di misura
  • DD.MM.YYYY
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C12533
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0948762
UMLS CUI-2
C0011008
DD.MM.YYYY
Peripheral Platelet Count
Descrizione

Peripheral Platelet Count

Tipo di dati

float

Unità di misura
  • 1000/uL
Alias
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C12520
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
UMLS CUI-1
C0005821
1000/uL
Date of Platelets
Descrizione

Date of Platelets

Tipo di dati

date

Unità di misura
  • DD.MM.YYYY
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C12520
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0005821
UMLS CUI-2
C0011008
DD.MM.YYYY
Hemoglobin
Descrizione

Hemoglobin

Tipo di dati

float

Unità di misura
  • g/dL
Alias
NCI Thesaurus Property
C16676
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
UMLS CUI-1
C0019046
g/dL
Date of Hemoglobin
Descrizione

LaboratoryProcedureHemoglobinResultDate

Tipo di dati

date

Unità di misura
  • DD.MM.YYYY
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C16676
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0019046
UMLS CUI-2
C0011008
DD.MM.YYYY
WBC
Descrizione

WBC

Tipo di dati

float

Unità di misura
  • /ul
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C12529
NCI Thesaurus Property-2
C20200
NCI Thesaurus ValueDomain
C38046
NCI Thesaurus ValueDomain-2
C25712
UMLS CUI-1
C0023508
/ul
Date of Serum Creatinine
Descrizione

Date of Serum Creatinine

Tipo di dati

date

Unità di misura
  • DD.MM.YYYY
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C25214
NCI Thesaurus Property-2
C38000
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0201976
UMLS CUI-2
C0011008
DD.MM.YYYY
Date of Serum Creatinine
Descrizione

Date of Serum Creatinine

Tipo di dati

date

Unità di misura
  • DD.MM.YYYY
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C25214
NCI Thesaurus Property-2
C38000
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0201976
UMLS CUI-2
C0011008
DD.MM.YYYY
BUN
Descrizione

BUN

Tipo di dati

float

Unità di misura
  • mg/dL
Alias
NCI Thesaurus Property
C20200
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property-2
C61019
NCI Thesaurus ValueDomain
C25712
UMLS CUI-1
C0005845
mg/dL
BUN date
Descrizione

LaboratoryProcedureBloodUreaNitrogenResultDate

Tipo di dati

date

Unità di misura
  • DD.MM.YYYY
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C20200
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property-2
C61019
UMLS CUI-1
C0005845
UMLS CUI-2
C0011008
DD.MM.YYYY
Creatinine
Descrizione

Creatinine

Tipo di dati

float

Unità di misura
  • mg/dL
Alias
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C399
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
UMLS CUI-1
C0201976
mg/dL
Creatinine ULN
Descrizione

Creatinine ULN

Tipo di dati

float

Unità di misura
  • mg/dL
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C399
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C25706
UMLS CUI-1
C0201976
UMLS CUI-2
C1519815
mg/dL
UPC ratio (RENAL FUNCTION )
Descrizione

UrinaryCreatinineProteinAssessmentValue

Tipo di dati

float

Alias
NCI Thesaurus ObjectClass
C25711
UMLS 2011AA ObjectClass
C1524119
NCI Thesaurus ObjectClass-2
C17021
UMLS 2011AA ObjectClass-2
C0033684
NCI Metathesaurus ObjectClass
C0010294
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
Protein from 24 hour Urine Collection (RENAL FUNCTION If yes mg)
Descrizione

UrinaryProteinCollectionValue

Tipo di dati

float

Unità di misura
  • g/24 hours
Alias
NCI Thesaurus Property
C25453
UMLS 2011AA Property
C1516698
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ObjectClass
C17021
UMLS 2011AA ObjectClass
C0033684
g/24 hours
Bilirubin, total
Descrizione

Bilirubin, total

Tipo di dati

float

Unità di misura
  • mg/dL
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C38037
NCI Thesaurus ValueDomain
C38046
NCI Thesaurus ValueDomain-2
C25712
UMLS CUI-1
C0201913
mg/dL
Total bilirubin, ULN
Descrizione

Total bilirubin, ULN

Tipo di dati

float

Unità di misura
  • mg/dL
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C38037
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C25706
UMLS CUI-1
C0201913
UMLS CUI-2
C1519815
mg/dL
Date of total Bilirubin
Descrizione

LaboratoryProcedureBilirubinOutcomeDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C305
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0201913
UMLS CUI-2
C0011008
AST (SGOT)
Descrizione

AST (SGOT)

Tipo di dati

float

Unità di misura
  • U/L
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C25202
NCI Thesaurus Property-2
C20200
NCI Thesaurus ValueDomain
C38046
NCI Thesaurus ValueDomain-2
C25712
UMLS CUI-1
C0201899
U/L
AST (SGOT) ULN
Descrizione

AST (SGOT) ULN

Tipo di dati

float

Unità di misura
  • U/L
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C25202
NCI Thesaurus Property-2
C20200
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C25706
UMLS CUI-1
C0242192
UMLS CUI-2
C1519815
U/L
AST Date
Descrizione

LaboratoryProcedureSerumGlutamicOxaloaceticTransferaseResultDate

Tipo di dati

date

Unità di misura
  • DD.MM.YYYY
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C25202
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0201899
UMLS CUI-2
C0011008
DD.MM.YYYY
ALT (SGPT)
Descrizione

ALT (SGPT)

Tipo di dati

float

Unità di misura
  • U/L
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C25293
NCI Thesaurus ValueDomain
C38046
NCI Thesaurus ValueDomain-2
C25712
UMLS CUI-1
C0201836
U/L
ALT ULN
Descrizione

ALT ULN

Tipo di dati

float

Unità di misura
  • U/L
Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C25293
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C25706
UMLS CUI-1
C0201836
UMLS CUI-2
C1519815
U/L
ALT date
Descrizione

ALT date

Tipo di dati

date

Unità di misura
  • DD.MM.YYYY
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C20200
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property-2
C25293
UMLS CUI-1
C0201836
UMLS CUI-2
C0011008
DD.MM.YYYY
PTT
Descrizione

PTT

Tipo di dati

float

Unità di misura
  • seconds
Alias
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C62656
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
UMLS CUI-1
C0030605
seconds
INR
Descrizione

INR

Tipo di dati

float

Alias
NCI Thesaurus Property
C20200
UMLS CUI-1
C0525032
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property-2
C25352
NCI Thesaurus ValueDomain
C25712
Non-protocol Therapy To Brain
Descrizione

Non-protocol Therapy To Brain

Has the patient taken anticoagulant agents?
Descrizione

AnticoagulantAgentAdministeredind-3

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C263
UMLS 2011AA ObjectClass
C0003280
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Specify
Descrizione

AnticoagulantAgentAdministeredSpecify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C263
UMLS 2011AA ObjectClass
C0003280
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Agents with proarrhythmic potential
Descrizione

SusceptibilityArrhythmiaAgentAdministeredInd-2

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C2881
UMLS 2011AA ObjectClass
C0003811
NCI Thesaurus ObjectClass-2
C1708
UMLS 2011AA ObjectClass-2
C0450442
NCI Thesaurus ObjectClass-3
C16505
UMLS 2011AA ObjectClass-3
C0220898
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Specify
Descrizione

SusceptibilityArrhythmiaAgentAdministeredSpecify

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C2881
UMLS 2011AA ObjectClass
C0003811
NCI Thesaurus ObjectClass-2
C1708
UMLS 2011AA ObjectClass-2
C0450442
NCI Thesaurus ObjectClass-3
C16505
UMLS 2011AA ObjectClass-3
C0220898
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C25382
UMLS 2011AA ValueDomain-2
C1521801
Herbal Products
Descrizione

TherapyComplementaryandAlternativeMedicineAdministeredInd-2

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C15178
UMLS 2011AA Property
C0002346
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
Specify
Descrizione

Alternative therapy, specify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS CUI-1
C0949216
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25415
NCI Thesaurus Property
C25382
Corticosteroids
Descrizione

Non-ProtocolCorticosteroidSystemicTherapyAdministeredInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C15698
UMLS 2011AA ObjectClass
C1515119
NCI Thesaurus ObjectClass-2
C2322
UMLS 2011AA ObjectClass-2
C0001617
NCI Thesaurus ObjectClass-3
C25590
UMLS 2011AA ObjectClass-3
C1518384
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Specify
Descrizione

Non-ProtocolCorticosteroidSystemicTherapyAdministeredSpecify

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C15698
UMLS 2011AA ObjectClass
C1515119
NCI Thesaurus ObjectClass-2
C2322
UMLS 2011AA ObjectClass-2
C0001617
NCI Thesaurus ObjectClass-3
C25590
UMLS 2011AA ObjectClass-3
C1518384
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Anticonvulsants
Descrizione

Non-ProtocolAnticonvulsantAgentSystemicTherapyAdministeredInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C15698
UMLS 2011AA ObjectClass
C1515119
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass-2
C1518384
NCI Thesaurus ObjectClass-3
C264
UMLS 2011AA ObjectClass-3
C0003286
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Specify
Descrizione

Non-ProtocolAnticonvulsantAgentSystemicTherapyAdministeredSpecify

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C15698
UMLS 2011AA ObjectClass
C1515119
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass-2
C1518384
NCI Thesaurus ObjectClass-3
C264
UMLS 2011AA ObjectClass-3
C0003286
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Date of Initial Dose (MM DD YYYY)
Descrizione

Treatment Start Date

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25509
UMLS CUI-1
C3173309
NCI Thesaurus Property-2
C25256
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
Date of Initial Dose (MM DD YYYY)
Descrizione

Treatment Start Date

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25509
UMLS CUI-1
C3173309
NCI Thesaurus Property-2
C25256
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
EIAEDS
Descrizione

PatientEnzymeInductionAnticonvulsantAgentPersonalMedicalHistoryInd-2

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus Property-2
C264
UMLS 2011AA Property-2
C0003286
NCI Thesaurus Property-3
C41564
UMLS 2011AA Property-3
C0014431
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Date of last dose (MM DD YYYY)
Descrizione

LastDoseDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus ObjectClass-2
C25551
UMLS 2011AA ObjectClass-2
C1517741
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Date of last dose (MM DD YYYY)
Descrizione

LastDoseDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus ObjectClass-2
C25551
UMLS 2011AA ObjectClass-2
C1517741
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Date of last dose (MM DD YYYY)
Descrizione

LastDoseDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus ObjectClass-2
C25551
UMLS 2011AA ObjectClass-2
C1517741
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Date of last dose (MM DD YYYY)
Descrizione

LastDoseDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus ObjectClass-2
C25551
UMLS 2011AA ObjectClass-2
C1517741
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Date of last dose (MM DD YYYY)
Descrizione

LastDoseDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus ObjectClass-2
C25551
UMLS 2011AA ObjectClass-2
C1517741
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NEIAEDS
Descrizione

PatientNegationEnzymeInductionAnticonvulsantAgentPersonalMedicalHistoryInd-2

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property-2
C18772
UMLS 2011AA Property-2
C0262926
NCI Thesaurus Property-3
C264
UMLS 2011AA Property-3
C0003286
NCI Thesaurus Property-4
C41564
UMLS 2011AA Property-4
C0014431
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Severe Active Comorbidity
Descrizione

Severe Active Comorbidity

Unstable angina
Descrizione

UnstableAnginaDiseasePresentInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C25594
NCI Thesaurus ObjectClass-2
C30103
NCI Thesaurus ObjectClass-3
C2991
NCI Thesaurus ObjectClass-4
C51221
NCI Thesaurus Property
C25626
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0002965
Transmural myocardial infaraction
Descrizione

TransmuralMyocardialInfarctionPatientPersonalMedicalHistoryInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C27996
NCI Metathesaurus ObjectClass
CL233186
NCI Thesaurus Property
C18772
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1275835
Infection (Acute bacterial or fungal infection)
Descrizione

ChronicDiseaseInfectionInd-2

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C26726
UMLS 2011AA Property
C0009450
NCI Thesaurus ObjectClass-2
C14141
UMLS 2011AA ObjectClass-2
C0205191
Cerebrovascular accident (including stroke)
Descrizione

PatientCerebrovascularAccidentHistoryInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C3390
NCI Thesaurus Property-2
C18772
UMLS CUI-1
C0559159
Peripheral Vascular Disease (PVD)
Descrizione

HistoryofPeripheralVascularDiseasePresentInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C66923
UMLS 2011AA ObjectClass
C1881056
Coagulation defects
Descrizione

FullDoseAnticoagulantAgentCurrentUseInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C25488
UMLS 2011AA ObjectClass
C0178602
NCI Thesaurus ObjectClass-2
C263
UMLS 2011AA ObjectClass-2
C0003280
NCI Thesaurus ObjectClass-3
C25517
UMLS 2011AA ObjectClass-3
C0443225
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus Property-2
C25340
UMLS 2011AA Property-2
C0457083
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
AIDS
Descrizione

PatientAcquiredImmunodeficiencySyndromeAssessmentInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C2851
UMLS CUI-1
C0001175
Significant vascular disease (e.g. Aortic Aneurysm, aortic dissection)
Descrizione

PersonVascularHistoryInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C13311
UMLS 2011AA Property
C1801960
NCI Thesaurus Property-2
C18772
UMLS 2011AA Property-2
C0262926
Serious nonhealing wound
Descrizione

PatientWoundComplicationPersonalMedicalHistoryInd-2

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3671
UMLS 2011AA Property
C0043250
NCI Thesaurus Property-2
C2959
UMLS 2011AA Property-2
C0009566
NCI Thesaurus Property-3
C18772
UMLS 2011AA Property-3
C0262926
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Footer Module
Descrizione

Footer Module

Comments
Descrizione

Research Comments

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Signature of Person Completing This Form
Descrizione

Responsible Person Signature

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C25657
NCI Thesaurus Property
C25678
Form Completion Date, Original
Descrizione

Form Completion Date

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367

Similar models

INSTRUCTIONS: Submit this form at protocol entry. Dates are recorded as mm-dd-yyyy unless otherwise specified

Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Module 1
Protocol ID RTOG
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
RTOG Case number
Item
RTOG Case #
text
C16960 (NCI Thesaurus ObjectClass)
C19778 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C49152 (NCI Thesaurus Property-2)
C25337 (NCI Thesaurus ValueDomain)
C1514695 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Institution Number
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Data amended
Item
Amended Data (INSTRUCTIONS: Complete form on web to unblind the protocol treatment arm)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Assessment
Age
Item
Age
integer
C16960 (NCI Thesaurus ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS CUI-1)
Item
Karnofsky Performance Status
text
C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C0206065 (UMLS CUI-1)
Code List
Karnofsky Performance Status
CL Item
Dead (0)
CL Item
Moribund, Fatal Processes Progressing Rapidly (10)
CL Item
Normal, No Complaints, No Evidence Of Disease (100)
CL Item
Very Sick, Hospitalization Indicated. Death Not Imminent (20)
CL Item
Severely Disabled, Hospitalization Indicated. Death Not Imminent (30)
CL Item
Disabled, Requires Special Care And Assistance (40)
CL Item
Requires Considerable Assistance And Frequent Medical Care (50)
CL Item
Requires Occasional Assistance, But Is Able To Care For Most Of His/her Needs (60)
CL Item
Cares For Self, Unable To Carry On Normal Activity Or To Do Active Work (70)
CL Item
Normal Activity With Effort; Some Signs Or Symptoms Of Disease (80)
CL Item
Able To Carry On Normal Activity; Minor Signs Or Symptoms Of Disease (90)
Item
Neurologic function
text
C25262 (NCI Thesaurus ObjectClass)
C0205494 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus ObjectClass-2)
C0542341 (UMLS 2011AA ObjectClass-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Code List
Neurologic function
CL Item
Minor Neurologic Symptoms, Fully Active At Home/work Without Assistance (Minor neurologic symptoms, fully active at home/work without assistance)
CL Item
Moderate Neurologic Symptoms, Fully Active At Home/work But Requires Assistance (Moderate neurologic symptoms, fully active at home/work but requires assistance)
CL Item
Moderate Neurologic Symptoms, Less Than Fully Active At Home/work And Requires Assitance (Moderate neurologic symptoms, less than fully active at home/work and requires assistance)
CL Item
No Neurologic Symptoms, Fully Active At Home/work Without Assistance (No neurologic symptoms, fully active at home/work without assistance)
CL Item
Severe Neurologic Symptoms, Totally Inactive Requiring Complete Assistance At Home Or Institution, Unable To Work (Severe neurologic symptoms, totally inactive requiring complete assistance at home or institution, unable to work)
Item Group
Disease Information
CancerInitialDiagnosisDate
Item
Initial Diagnosis Date (OF GBM/GLIOSARCOMA MM DD YYYY)
date
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Item
Extent of Resection
text
C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C25698 (NCI Thesaurus Property)
C15232 (NCI Thesaurus Property-2)
C0728940 (UMLS 2011AA Property)
C25332 (NCI Thesaurus Property-3)
C0439792 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Extent of Resection
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Subtotal (Subtotal)
CL Item
Total (gross) (Total (gross))
BrainLesionSiteSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12439 (NCI Thesaurus ObjectClass-2)
C0006104 (UMLS 2011AA ObjectClass-2)
PatientSurgicalResectionDate
Item
Date of Resection (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25698 (NCI Thesaurus Property)
C15232 (NCI Thesaurus Property-2)
C0728940 (UMLS 2011AA Property)
AgreementCentralPathologyReviewGlioblastomaGliosarcomaPerformedInd-2
Item
Central pathology confirmed GBM/gliosarcoma
boolean
C71684 (NCI Thesaurus ObjectClass)
C2347585 (UMLS 2011AA ObjectClass)
C25369 (NCI Thesaurus ObjectClass-2)
C0680240 (UMLS 2011AA ObjectClass-2)
C3058 (NCI Thesaurus Property)
C0017636 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C3796 (NCI Thesaurus Property-3)
C0206726 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
Sufficient tissue for MGMT/molecular profile analysis
text
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25457 (NCI Thesaurus Property-2)
C0348080 (UMLS 2011AA Property-2)
C17315 (NCI Thesaurus Property-3)
C0069197 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Sufficient tissue for MGMT/molecular profile analysis
CL Item
Usable (Usable)
CL Item
Inadequate (Inadequate)
Item Group
Pre-study Scans
DiagnosticImagingProcedureDate
Item
Image date (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C25218 (NCI Thesaurus Property)
C1948041 (UMLS 2011AA Property)
Item
Assessment Type
text
C25284 (NCI Thesaurus ValueDomain)
C2911685 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C16847 (NCI Thesaurus Property)
Code List
Assessment Type
CL Item
Mri Scan (MRI scan)
CL Item
Ct Scan (CT scan)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Evaluation method, specify
Item
Other Specify
text
C25685 (NCI Thesaurus ValueDomain)
C2911685 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C1521902 (UMLS CUI-2)
C16847 (NCI Thesaurus Property)
TumorLargestDimensionMeasurement
Item
Dimension 1 (mm)
float
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25550 (NCI Thesaurus Property)
C0443228 (UMLS 2011AA Property)
C25483 (NCI Thesaurus Property-2)
C0439534 (UMLS 2011AA Property-2)
TumorSecondDimensionMeasurement
Item
Dimension 2 (mm)
float
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus Property)
C0205436 (UMLS 2011AA Property)
C25483 (NCI Thesaurus Property-2)
C0439534 (UMLS 2011AA Property-2)
Item Group
Pre-study Scans
DiagnosticImagingProcedureDate
Item
Image date (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C25218 (NCI Thesaurus Property)
C1948041 (UMLS 2011AA Property)
Item
Assessment Type
text
C25284 (NCI Thesaurus ValueDomain)
C2911685 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C16847 (NCI Thesaurus Property)
Code List
Assessment Type
CL Item
Mri Scan (MRI scan)
CL Item
Ct Scan (CT scan)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Evaluation method, specify
Item
Other Specify
text
C25685 (NCI Thesaurus ValueDomain)
C2911685 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C1521902 (UMLS CUI-2)
C16847 (NCI Thesaurus Property)
TumorLargestDimensionMeasurement
Item
Dimension 1 (mm)
float
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25550 (NCI Thesaurus Property)
C0443228 (UMLS 2011AA Property)
C25483 (NCI Thesaurus Property-2)
C0439534 (UMLS 2011AA Property-2)
TumorSecondDimensionMeasurement
Item
Dimension 2 (mm)
float
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus Property)
C0205436 (UMLS 2011AA Property)
C25483 (NCI Thesaurus Property-2)
C0439534 (UMLS 2011AA Property-2)
Item Group
Location Of Primary
Item
Site of Lesion
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12439 (NCI Thesaurus ObjectClass-2)
C0006104 (UMLS 2011AA ObjectClass-2)
Code List
Site of Lesion
CL Item
Frontal Lobe (Frontal)
C12352 (NCI Thesaurus)
C0016733 (UMLS 2011AA)
CL Item
Temporal Lobe (Temporal)
C12353 (NCI Thesaurus)
C0039485 (UMLS 2011AA)
CL Item
Parietal Lobe (Parietal)
C12354 (NCI Thesaurus)
C0030560 (UMLS 2011AA)
CL Item
Occipital Lobe (Occipital)
C12355 (NCI Thesaurus)
C0028785 (UMLS 2011AA)
CL Item
Basal Ganglia (Basal ganglia)
C12447 (NCI Thesaurus)
C0004781 (UMLS 2011AA)
CL Item
Thalamus (Thalamus)
C12459 (NCI Thesaurus)
C0039729 (UMLS 2011AA)
CL Item
Cerebellum (Cerebellum)
C12445 (NCI Thesaurus)
C0007765 (UMLS 2011AA)
CL Item
Brainstem (Brainstem)
CL Item
Corpus Callosum (Corpus callosum)
C12446 (NCI Thesaurus)
C0010090 (UMLS 2011AA)
CL Item
Spinal Cord (c1 And Below) (Spinal cord)
CL Item
Other, Specify (Other specify)
BrainLesionSiteSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12439 (NCI Thesaurus ObjectClass-2)
C0006104 (UMLS 2011AA ObjectClass-2)
Item
Primary Tumor Laterality
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25251 (NCI Thesaurus ObjectClass-2)
C0205225 (UMLS 2011AA ObjectClass-2)
C25185 (NCI Thesaurus Property)
C0332304 (UMLS 2011AA Property)
Code List
Primary Tumor Laterality
CL Item
Right (Right)
C25228 (NCI Thesaurus)
C0205090 (UMLS 2011AA)
CL Item
Left (Left)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
CL Item
Bilateral (Bilateral)
C13332 (NCI Thesaurus)
C0238767 (UMLS 2011AA)
CL Item
Unknown/not Documented (Unknown)
Item Group
Baseline Lab Values (hematologic)
ANC
Item
ANC
float
C25294 (NCI Thesaurus ObjectClass)
C12533 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25304 (NCI Thesaurus ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C0948762 (UMLS CUI-1)
ANC date
Item
Date of ANC
date
C25164 (NCI Thesaurus ValueDomain)
C12533 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0948762 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Platelets
Item
Peripheral Platelet Count
float
C20200 (NCI Thesaurus Property)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0005821 (UMLS CUI-1)
Platelets date
Item
Date of Platelets
date
C25164 (NCI Thesaurus ValueDomain)
C20200 (NCI Thesaurus Property)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0005821 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Hemoglobin
Item
Hemoglobin
float
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0019046 (UMLS CUI-1)
Hemoglobin date
Item
Date of Hemoglobin
date
C25164 (NCI Thesaurus ValueDomain)
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0019046 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Leukocytes (WBC)
Item
WBC
float
C25294 (NCI Thesaurus ObjectClass)
C12529 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C38046 (NCI Thesaurus ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C0023508 (UMLS CUI-1)
Creatinine, serum date
Item
Date of Serum Creatinine
date
C25164 (NCI Thesaurus ValueDomain)
C25214 (NCI Thesaurus Property)
C38000 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0201976 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Creatinine, serum date
Item
Date of Serum Creatinine
date
C25164 (NCI Thesaurus ValueDomain)
C25214 (NCI Thesaurus Property)
C38000 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0201976 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
BUN
Item
BUN
float
C20200 (NCI Thesaurus Property)
C25294 (NCI Thesaurus ObjectClass)
C61019 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C0005845 (UMLS CUI-1)
BUN date
Item
BUN date
date
C25164 (NCI Thesaurus ValueDomain)
C20200 (NCI Thesaurus Property)
C25294 (NCI Thesaurus ObjectClass)
C61019 (NCI Thesaurus Property-2)
C0005845 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Creatinine, Serum
Item
Creatinine
float
C20200 (NCI Thesaurus Property)
C399 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0201976 (UMLS CUI-1)
Creatinine, Serum ULN
Item
Creatinine ULN
float
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C399 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C0201976 (UMLS CUI-1)
C1519815 (UMLS CUI-2)
UrinaryCreatinineProteinAssessmentValue
Item
UPC ratio (RENAL FUNCTION )
float
C25711 (NCI Thesaurus ObjectClass)
C1524119 (UMLS 2011AA ObjectClass)
C17021 (NCI Thesaurus ObjectClass-2)
C0033684 (UMLS 2011AA ObjectClass-2)
C0010294 (NCI Metathesaurus ObjectClass)
C25367 (NCI Thesaurus Property)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
UrinaryProteinCollectionValue
Item
Protein from 24 hour Urine Collection (RENAL FUNCTION If yes mg)
float
C25453 (NCI Thesaurus Property)
C1516698 (UMLS 2011AA Property)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C17021 (NCI Thesaurus ObjectClass)
C0033684 (UMLS 2011AA ObjectClass)
Bilirubin, total
Item
Bilirubin, total
float
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C38037 (NCI Thesaurus Property-2)
C38046 (NCI Thesaurus ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C0201913 (UMLS CUI-1)
Bilirubin, total ULN
Item
Total bilirubin, ULN
float
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C38037 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C0201913 (UMLS CUI-1)
C1519815 (UMLS CUI-2)
Bilirubin, total date
Item
Date of total Bilirubin
date
C25164 (NCI Thesaurus ValueDomain)
C20200 (NCI Thesaurus Property)
C305 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0201913 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
AST
Item
AST (SGOT)
float
C25294 (NCI Thesaurus ObjectClass)
C25202 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C38046 (NCI Thesaurus ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C0201899 (UMLS CUI-1)
AST ULN
Item
AST (SGOT) ULN
float
C25294 (NCI Thesaurus ObjectClass)
C25202 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C0242192 (UMLS CUI-1)
C1519815 (UMLS CUI-2)
AST date
Item
AST Date
date
C25164 (NCI Thesaurus ValueDomain)
C25202 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0201899 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
ALT
Item
ALT (SGPT)
float
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C25293 (NCI Thesaurus Property-2)
C38046 (NCI Thesaurus ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C0201836 (UMLS CUI-1)
ALT ULN
Item
ALT ULN
float
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C25293 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C0201836 (UMLS CUI-1)
C1519815 (UMLS CUI-2)
ALT date
Item
ALT date
date
C25164 (NCI Thesaurus ValueDomain)
C20200 (NCI Thesaurus Property)
C25294 (NCI Thesaurus ObjectClass)
C25293 (NCI Thesaurus Property-2)
C0201836 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
PTT
Item
PTT
float
C20200 (NCI Thesaurus Property)
C62656 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0030605 (UMLS CUI-1)
INR
Item
INR
float
C20200 (NCI Thesaurus Property)
C0525032 (UMLS CUI-1)
C25294 (NCI Thesaurus ObjectClass)
C25352 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
Item Group
Non-protocol Therapy To Brain
AnticoagulantAgentAdministeredind-3
Item
Has the patient taken anticoagulant agents?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C263 (NCI Thesaurus ObjectClass)
C0003280 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
AnticoagulantAgentAdministeredSpecify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C263 (NCI Thesaurus ObjectClass)
C0003280 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
SusceptibilityArrhythmiaAgentAdministeredInd-2
Item
Agents with proarrhythmic potential
boolean
C2881 (NCI Thesaurus ObjectClass)
C0003811 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass-2)
C0450442 (UMLS 2011AA ObjectClass-2)
C16505 (NCI Thesaurus ObjectClass-3)
C0220898 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
SusceptibilityArrhythmiaAgentAdministeredSpecify
Item
Specify
text
C2881 (NCI Thesaurus ObjectClass)
C0003811 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass-2)
C0450442 (UMLS 2011AA ObjectClass-2)
C16505 (NCI Thesaurus ObjectClass-3)
C0220898 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus ValueDomain-2)
C1521801 (UMLS 2011AA ValueDomain-2)
TherapyComplementaryandAlternativeMedicineAdministeredInd-2
Item
Herbal Products
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C15178 (NCI Thesaurus Property)
C0002346 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
Alternative therapy, specify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C0949216 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25415 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)
Non-ProtocolCorticosteroidSystemicTherapyAdministeredInd-3
Item
Corticosteroids
boolean
C15698 (NCI Thesaurus ObjectClass)
C1515119 (UMLS 2011AA ObjectClass)
C2322 (NCI Thesaurus ObjectClass-2)
C0001617 (UMLS 2011AA ObjectClass-2)
C25590 (NCI Thesaurus ObjectClass-3)
C1518384 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Non-ProtocolCorticosteroidSystemicTherapyAdministeredSpecify
Item
Specify
text
C15698 (NCI Thesaurus ObjectClass)
C1515119 (UMLS 2011AA ObjectClass)
C2322 (NCI Thesaurus ObjectClass-2)
C0001617 (UMLS 2011AA ObjectClass-2)
C25590 (NCI Thesaurus ObjectClass-3)
C1518384 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Non-ProtocolAnticonvulsantAgentSystemicTherapyAdministeredInd-3
Item
Anticonvulsants
boolean
C15698 (NCI Thesaurus ObjectClass)
C1515119 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
C264 (NCI Thesaurus ObjectClass-3)
C0003286 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Non-ProtocolAnticonvulsantAgentSystemicTherapyAdministeredSpecify
Item
Specify
text
C15698 (NCI Thesaurus ObjectClass)
C1515119 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
C264 (NCI Thesaurus ObjectClass-3)
C0003286 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Treatment Start Date
Item
Date of Initial Dose (MM DD YYYY)
date
C15368 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus Property)
C3173309 (UMLS CUI-1)
C25256 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
Treatment Start Date
Item
Date of Initial Dose (MM DD YYYY)
date
C15368 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus Property)
C3173309 (UMLS CUI-1)
C25256 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
PatientEnzymeInductionAnticonvulsantAgentPersonalMedicalHistoryInd-2
Item
EIAEDS
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C264 (NCI Thesaurus Property-2)
C0003286 (UMLS 2011AA Property-2)
C41564 (NCI Thesaurus Property-3)
C0014431 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
LastDoseDate
Item
Date of last dose (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass-2)
C1517741 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
LastDoseDate
Item
Date of last dose (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass-2)
C1517741 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
LastDoseDate
Item
Date of last dose (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass-2)
C1517741 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
LastDoseDate
Item
Date of last dose (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass-2)
C1517741 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
LastDoseDate
Item
Date of last dose (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass-2)
C1517741 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
PatientNegationEnzymeInductionAnticonvulsantAgentPersonalMedicalHistoryInd-2
Item
NEIAEDS
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C264 (NCI Thesaurus Property-3)
C0003286 (UMLS 2011AA Property-3)
C41564 (NCI Thesaurus Property-4)
C0014431 (UMLS 2011AA Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item Group
Severe Active Comorbidity
Angina pectoris, unstable
Item
Unstable angina
boolean
C25594 (NCI Thesaurus ObjectClass)
C30103 (NCI Thesaurus ObjectClass-2)
C2991 (NCI Thesaurus ObjectClass-3)
C51221 (NCI Thesaurus ObjectClass-4)
C25626 (NCI Thesaurus Property)
C38148 (NCI Thesaurus ValueDomain)
C0002965 (UMLS CUI-1)
History of myocardial infarction
Item
Transmural myocardial infaraction
boolean
C16960 (NCI Thesaurus ObjectClass)
C27996 (NCI Thesaurus ObjectClass-2)
CL233186 (NCI Metathesaurus ObjectClass)
C18772 (NCI Thesaurus Property)
C38148 (NCI Thesaurus ValueDomain)
C1275835 (UMLS CUI-1)
ChronicDiseaseInfectionInd-2
Item
Infection (Acute bacterial or fungal infection)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C26726 (NCI Thesaurus Property)
C0009450 (UMLS 2011AA Property)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)
History of stroke
Item
Cerebrovascular accident (including stroke)
boolean
C38148 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C3390 (NCI Thesaurus Property)
C18772 (NCI Thesaurus Property-2)
C0559159 (UMLS CUI-1)
HistoryofPeripheralVascularDiseasePresentInd-3
Item
Peripheral Vascular Disease (PVD)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C66923 (NCI Thesaurus ObjectClass)
C1881056 (UMLS 2011AA ObjectClass)
FullDoseAnticoagulantAgentCurrentUseInd-3
Item
Coagulation defects
boolean
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C263 (NCI Thesaurus ObjectClass-2)
C0003280 (UMLS 2011AA ObjectClass-2)
C25517 (NCI Thesaurus ObjectClass-3)
C0443225 (UMLS 2011AA ObjectClass-3)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property-2)
C0457083 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
AIDS
Item
AIDS
boolean
C38148 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C2851 (NCI Thesaurus Property-2)
C0001175 (UMLS CUI-1)
PersonVascularHistoryInd-3
Item
Significant vascular disease (e.g. Aortic Aneurysm, aortic dissection)
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C13311 (NCI Thesaurus Property)
C1801960 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
PatientWoundComplicationPersonalMedicalHistoryInd-2
Item
Serious nonhealing wound
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3671 (NCI Thesaurus Property)
C0043250 (UMLS 2011AA Property)
C2959 (NCI Thesaurus Property-2)
C0009566 (UMLS 2011AA Property-2)
C18772 (NCI Thesaurus Property-3)
C0262926 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item Group
Footer Module
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Responsible Person Signature
Item
Signature of Person Completing This Form
text
C25704 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C25678 (NCI Thesaurus Property)
Form Completion Date
Item
Form Completion Date, Original
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)

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