ID

2244

Beskrivning

PQ RTOG Phase III Multiple Brain Metastases Fact Subscale Radiation Therapy and Stereotactic Radiosurgery With or Without Temozolomide or Erlotinib in Treating Patients With Brain Metastases Secondary to Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D7FA7BFE-292F-6626-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D7FA7BFE-292F-6626-E034-0003BA12F5E7

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2021-09-27 2021-09-27 -
Uppladdad den

19 september 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00096265 Quality of Life - PQ RTOG Phase III Multiple Brain Metastases Fact Subscale - 2277326v3.0

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: PQ RTOG Phase III Multiple Brain Metastases Fact Subscale
    1. No Instruction available.
Header
Beskrivning

Header

[RTOG Study No.]
Beskrivning

ProtocolRTOGIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Case #
Beskrivning

Case#

Datatyp

text

Institution
Beskrivning

InstitutionName

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution No.
Beskrivning

InstitutionIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participant's Initials
Beskrivning

PatientInitialsName

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Participant's I.D. No.
Beskrivning

PatientCoordinatingIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25462
UMLS 2011AA Property
C0700114
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Physical Well-being
Beskrivning

Physical Well-being

I am able to concentrate
Beskrivning

Iamabletoconcentrate

Datatyp

text

I have had seizures (convulsions)
Beskrivning

Ihavehadseizures(convulsions)

Datatyp

text

I can remember new things
Beskrivning

Icanremembernewthings

Datatyp

text

I get frustrated that I cannot do things I used to
Beskrivning

IgetfrustratedthatIcannotdothingsIusedto

Datatyp

text

I am afraid of having a seizure (convulsion)
Beskrivning

Iamafraidofhavingaseizure(convulsion)

Datatyp

text

I have trouble with my eyesight
Beskrivning

Ihavetroublewithmyeyesight

Datatyp

text

I feel independent
Beskrivning

Ifeelindependent

Datatyp

text

I have trouble hearing
Beskrivning

Ihavetroublehearing

Datatyp

text

I am able to find the right word(s) to say what I mean
Beskrivning

Iamabletofindtherightword(s)tosaywhatImean

Datatyp

text

I have difficulty expressing my thoughts
Beskrivning

Ihavedifficultyexpressingmythoughts

Datatyp

text

I am bothered by the change in my personality
Beskrivning

Iambotheredbythechangeinmypersonality

Datatyp

text

I am able to make decisions and take responsibility
Beskrivning

Iamabletomakedecisionsandtakeresponsibility

Datatyp

text

I am bothered by the drop in my contribution to the family
Beskrivning

Iambotheredbythedropinmycontributiontothefamily

Datatyp

text

I am able to put my thoughts together
Beskrivning

Iamabletoputmythoughtstogether

Datatyp

text

I need help in caring for myself (bathing, dressing, eating)
Beskrivning

Ineedhelpincaringformyself(bathing,dressing,eating)

Datatyp

text

I am able to put my thoughts into action
Beskrivning

Iamabletoputmythoughtsintoaction

Datatyp

text

I am able to read like I used to
Beskrivning

IamabletoreadlikeIusedto

Datatyp

text

I am able to write like I used to
Beskrivning

IamabletowritelikeIusedto

Datatyp

text

I am able to drive a vehicle (my car, truck, etc.)
Beskrivning

Iamabletodriveavehicle(mycar,truck,etc.)

Datatyp

text

I have trouble feeling sensations in my arms, hands, or legs
Beskrivning

Ihavetroublefeelingsensationsinmyarms,hands,orlegs

Datatyp

text

I have weakness in my arms or legs
Beskrivning

Ihaveweaknessinmyarmsorlegs

Datatyp

text

I have trouble with coordination
Beskrivning

Ihavetroublewithcoordination

Datatyp

text

I get headaches
Beskrivning

Igetheadaches

Datatyp

text

Additional Concerns
Beskrivning

Additional Concerns

I have been short of breath
Beskrivning

QualityofLifeDyspneaEvaluationScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property
C2998
UMLS 2011AA Property
C0013404
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I am losing weight
Beskrivning

PatientWeightLossAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C3445
UMLS 2011AA Property
C0043096
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
My thinking is clear
Beskrivning

Mythinkingisclear

Datatyp

text

I have been coughing
Beskrivning

Ihavebeencoughing

Datatyp

text

I am bothered by hair loss
Beskrivning

Iambotheredbyhairloss

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have a good appetite
Beskrivning

PatientAppetiteAssessmentQualityofLifeScale

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C25152
UMLS 2011AA Property
C0003618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I feel tightness in my chest
Beskrivning

Ifeeltightnessinmychest

Datatyp

text

Breathing is easy for me
Beskrivning

Breathingiseasyforme

Datatyp

text

Comments
Beskrivning

ResearchCommentsText

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Date
Beskrivning

ResponsiblePersonSignatureDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Have you ever smoked?
Beskrivning

Haveyoueversmoked?

Datatyp

text

If yes
Beskrivning

Ifyes

Datatyp

text

I regret smoking
Beskrivning

Iregretsmoking

Datatyp

text

Patient's signature
Beskrivning

Patient'ssignature

Datatyp

text

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Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: PQ RTOG Phase III Multiple Brain Metastases Fact Subscale
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Header
Item
[RTOG Study No.]
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL.1
Code List
[RTOG Study No.]
CL Item
RTOG Study 0320 (RTOG Study 0320)
Case#
Item
Case #
text
InstitutionName
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InstitutionIdentifierNumber
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Participant's Initials
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientCoordinatingIdentifierNumber
Item
Participant's I.D. No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Physical Well-being
Item
I am able to concentrate
text
CL.2
Code List
I am able to concentrate
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I have had seizures (convulsions)
text
CL.3
Code List
I have had seizures (convulsions)
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I can remember new things
text
CL.4
Code List
I can remember new things
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I get frustrated that I cannot do things I used to
text
CL.5
Code List
I get frustrated that I cannot do things I used to
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am afraid of having a seizure (convulsion)
text
CL.6
Code List
I am afraid of having a seizure (convulsion)
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I have trouble with my eyesight
text
CL.7
Code List
I have trouble with my eyesight
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I feel independent
text
CL.8
Code List
I feel independent
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I have trouble hearing
text
CL.9
Code List
I have trouble hearing
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am able to find the right word(s) to say what I mean
text
CL.10
Code List
I am able to find the right word(s) to say what I mean
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I have difficulty expressing my thoughts
text
CL.11
Code List
I have difficulty expressing my thoughts
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am bothered by the change in my personality
text
CL.12
Code List
I am bothered by the change in my personality
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am able to make decisions and take responsibility
text
CL.13
Code List
I am able to make decisions and take responsibility
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am bothered by the drop in my contribution to the family
text
CL.14
Code List
I am bothered by the drop in my contribution to the family
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am able to put my thoughts together
text
CL.15
Code List
I am able to put my thoughts together
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I need help in caring for myself (bathing, dressing, eating)
text
CL.16
Code List
I need help in caring for myself (bathing, dressing, eating)
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am able to put my thoughts into action
text
CL.17
Code List
I am able to put my thoughts into action
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am able to read like I used to
text
CL.18
Code List
I am able to read like I used to
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am able to write like I used to
text
CL.19
Code List
I am able to write like I used to
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I am able to drive a vehicle (my car, truck, etc.)
text
CL.20
Code List
I am able to drive a vehicle (my car, truck, etc.)
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I have trouble feeling sensations in my arms, hands, or legs
text
CL.21
Code List
I have trouble feeling sensations in my arms, hands, or legs
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I have weakness in my arms or legs
text
CL.22
Code List
I have weakness in my arms or legs
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I have trouble with coordination
text
CL.23
Code List
I have trouble with coordination
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I get headaches
text
CL.24
Code List
I get headaches
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item Group
Additional Concerns
Item
I have been short of breath
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C2998 (NCI Thesaurus Property)
C0013404 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.25
Code List
I have been short of breath
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I am losing weight
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3445 (NCI Thesaurus Property)
C0043096 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.26
Code List
I am losing weight
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
My thinking is clear
text
CL.27
Code List
My thinking is clear
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I have been coughing
text
CL.28
Code List
I have been coughing
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I am bothered by hair loss
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.29
Code List
I am bothered by hair loss
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have a good appetite
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25152 (NCI Thesaurus Property)
C0003618 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.30
Code List
I have a good appetite
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I feel tightness in my chest
text
CL.31
Code List
I feel tightness in my chest
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
Breathing is easy for me
text
CL.32
Code List
Breathing is easy for me
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
ResponsiblePersonSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
Item
Have you ever smoked?
text
CL.33
Code List
Have you ever smoked?
CL Item
No (No)
CL Item
Yes (Yes)
Item
If yes
text
CL.34
Code List
If yes
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Item
I regret smoking
text
CL.35
Code List
I regret smoking
CL Item
Not At All (Not at all)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite A Bit (Quite a bit)
CL Item
Very Much (Very much)
Patient'ssignature
Item
Patient's signature
text
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