ID
43366
Beschrijving
Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer NCT00024102 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0
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Trefwoorden
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- 18-12-14 18-12-14 - Martin Dugas
- 20-03-15 20-03-15 - Martin Dugas
- 20-09-21 20-09-21 -
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20 september 2021
DOI
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer (NCT00024102)
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Beschrijving
Patient characteristics
Alias
- UMLS CUI-1
- C0815172
Beschrijving
Othercancersorleukemia
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschrijving
How much does it interfere with your activities: Other cancers or leukemia (b.)
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschrijving
Arthritis,rheumatism,orotherconnectivetissuedisorders
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschrijving
Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Glaucoma (c.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0017601
Beschrijving
Howmuchdoesitinterferewithyouractivities:Glaucoma
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschrijving
Emphysema or Chronic Bronchitis (d.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschrijving
Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
HighBloodPressure
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0020538
Beschrijving
Howmuchdoesitinterferewithyouractivities:HighBloodPressure
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Heartdisease
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0018799
Beschrijving
Howmuchdoesitinterferewithyouractivities:Heartdisease
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschrijving
Circulationtroubleinarmsorlegs
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0728936
Beschrijving
Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschrijving
Diabetes (h.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0011849
Beschrijving
Howmuchdoesitinterferewithyouractivities:Diabetes
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Stomach or intestinal disorders (i.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschrijving
Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Osteoporosis (j.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0029456
Beschrijving
Howmuchdoesitinterferewithyouractivities:Osteoporosis
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Chronic Liver or Kidney Disease (k.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschrijving
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Stroke (l.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0038454
Beschrijving
How much does it interfere with your activities: Stroke (m.)
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Depression (m.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0011581
Beschrijving
How much does it interfere with your activities: Depression
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Howisyoureyesight(withglassesorcontacts)?
Datatype
text
Alias
- UMLS CUI-1
- C0042812
Beschrijving
Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
Datatype
text
Alias
- UMLS CUI-1
- C0018767
Beschrijving
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Beschrijving
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
Datatype
text
Beschrijving
Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)
Datatype
text
Beschrijving
how much does this interfere with your activities? (mark one with an X)
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Beschrijving
Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?
Datatype
text
Beschrijving
Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?
Datatype
text
Beschrijving
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Datatype
text
Beschrijving
Counseling
Beschrijving
Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0849496
Beschrijving
What type of counseling or treatment did you receive? (mark all that apply with an X)
Datatype
text
Beschrijving
Other, specify (type of counseling or treatment received) (8c.)
Datatype
text
Beschrijving
Check any of these services that you are still receiving (mark all that apply with an X)
Datatype
text
Beschrijving
Other,specify(servicesthatyouarestillreceiving)
Datatype
text
Beschrijving
Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0849496
Beschrijving
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Datatype
text
Beschrijving
Other,specify(servicesthatyouarestillreceiving;follow-up)
Datatype
text
Beschrijving
Medication
Alias
- UMLS CUI-1
- C0013227
Beschrijving
Medicine to treat nausea and/or vomiting
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschrijving
Medicine to treat diarrhea
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0003292
Beschrijving
Medicinetoreducefeelingverytired[fatigue]
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
Medicinetoreduceswellinginhandsorfeet
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
Medicineorcreamtotreatmouthsores
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
Painmedicineforhandsorfeet
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschrijving
Other,specify
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)
Datatype
text
Beschrijving
Arthritismedicine
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Arthritis medicine (b.)
Datatype
text
Beschrijving
Prescriptionpainkiller
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Datatype
text
Alias
- UMLS CUI-1
- C0002771
- UMLS CUI-2
- C0439603
Beschrijving
Over-thecounterpainkillers
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
Datatype
text
Beschrijving
Highbloodpressuremedicine
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: High blood pressure medicine (e.)
Datatype
text
Beschrijving
Pillstomakeyoulosewaterorsalt
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Pills to make you lose water or salt (f.)
Datatype
text
Beschrijving
Digoxinpillsfortheheart
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Datatype
text
Beschrijving
Nitroglycerinforchestpain
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Datatype
text
Beschrijving
Bloodthinnermedicine
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Blood thinner medicine (anticoagulants)
Datatype
text
Beschrijving
Medicinetoimprovecirculation
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Medicine to improve circulation (j.)
Datatype
text
Beschrijving
Insulin injections for diabetes (j.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0199782
Beschrijving
If Taken, How Often: Insulin injections for diabetes (k.)
Datatype
text
Beschrijving
Pillsfordiabetes
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Pills for diabetes (l.)
Datatype
text
Beschrijving
Ulcermedicine
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Ulcer medicine (m.)
Datatype
text
Beschrijving
Asthma medicines (m.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282556
Beschrijving
If Taken, How Often: Asthma medicines (n.)
Datatype
text
Beschrijving
Seizuremedicines
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Seizure medicines (like Dilantin)
Datatype
text
Beschrijving
Thyroidpills
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Thyroid pills (p.)
Datatype
text
Beschrijving
Cortisonepillsorinjections
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0010137
Beschrijving
If Taken, How Often: Cortisone pills or injections (q.)
Datatype
text
Beschrijving
Antibiotics (q.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0003232
Beschrijving
If Taken, How Often: Antibiotics (r.)
Datatype
text
Beschrijving
Tranquilizersormedicineforyournerves
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0040614
Beschrijving
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Datatype
text
Beschrijving
Prescriptionsleepingpills
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0599396
Beschrijving
If Taken, How Often: Prescription sleeping pills (t.)
Datatype
text
Beschrijving
Over-the-counterpillstohelpyousleep
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Datatype
text
Beschrijving
Hormones (male or female)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0019932
Beschrijving
If Taken, How Often: Hormones (v.)
Datatype
text
Beschrijving
Allergy medicines (v.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282555
Beschrijving
If Taken, How Often: Allergy medicines (w.)
Datatype
text
Beschrijving
Laxatives (w.)
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282090
Beschrijving
If Taken, How Often: Laxatives (x.)
Datatype
text
Beschrijving
Eyedropsforglaucoma
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Eye drops for glaucoma (y.)
Datatype
text
Beschrijving
Calciumtablets
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Calcium tablets (z.)
Datatype
text
Beschrijving
Vitaminsand/orminerals
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Datatype
text
Beschrijving
Herbalmedicines
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0242388
Beschrijving
If Taken, How Often: Herbal medicines (12.)
Datatype
text
Beschrijving
Have you taken any other medicines in the past month?
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1522602
Beschrijving
NameofMedicine
Datatype
text
Beschrijving
If Taken, How Often?
Datatype
text
Alias
- UMLS CUI-1
- C3476109
Similar models
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
C1516238 (UMLS CUI-2)
C1516238 (UMLS CUI-2)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0332307 (UMLS CUI-1)
C0017601 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0020538 (UMLS CUI-1)
C0018799 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0728936 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0011849 (UMLS CUI-1)
C0029456 (UMLS CUI-1)
C0038454 (UMLS CUI-1)
C0011581 (UMLS CUI-1)
C0205170 (UMLS CUI-1)
C0205170 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C1298908 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0849496 (UMLS CUI-1)
C0849496 (UMLS CUI-1)
C0003292 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0439603 (UMLS CUI-2)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0199782 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0282556 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0010137 (UMLS CUI-1)
C0003232 (UMLS CUI-1)
C0040614 (UMLS CUI-1)
C0599396 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C0019932 (UMLS CUI-1)
C0282555 (UMLS CUI-1)
C0282090 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0242388 (UMLS CUI-1)
C1522602 (UMLS CUI-1)