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ID
5499
Description
Quality of Life Questionnaire Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0E240A0-FD2A-46A0-E034-080020C9C0E0
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Keywords
Versions (5)
- 8/26/12 8/26/12 -
- 8/7/14 8/7/14 - Martin Dugas
- 3/21/15 3/21/15 - Martin Dugas
- 4/10/21 4/10/21 - Ahmed Rafee, MD
- 9/20/21 9/20/21 -
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August 7, 2014
DOI
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053898 Quality of Life - Quality of Life Questionnaire - 2035063v3.0
NSABP Protocol B-35 [At bottom ] Record the first three letters of patient's last name and study ID on each of the remaining pages before giving the questionnaire to the patient.
Similar models
NSABP Protocol B-35 [At bottom ] Record the first three letters of patient's last name and study ID on each of the remaining pages before giving the questionnaire to the patient.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
FirstThreeLettersofPatient?sLastName
Item
First Three Letters of Patient?s Last Name
text
PatientStudyID
Item
Patient Study ID
text
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate Name
text
PersonFormAdministrationLastName
Item
Staff member administering form
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain)
C1517741 (UMLS 2011AA ValueDomain)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain)
C1517741 (UMLS 2011AA ValueDomain)
Unnamed
Item
Unnamed
text
Phone
Item
Phone
text
Item
Are data amended? (If yes, circle amended items in red.)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Baseline (Baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
C1442488 (UMLS 2011AA)
CL Item
6 Month Follow-up (6 month follow-up)
CL Item
12 Month Follow-up (12 month follow-up)
CL Item
18 Month Follow-up (18 month follow-up)
CL Item
2 Year Follow-up (2 year follow-up)
CL Item
30 Month Follow-up (30 month follow-up)
CL Item
3 Year Follow-up (3 year follow-up)
CL Item
42 Month Follow-up (42 month follow-up)
CL Item
4 Year Follow-up (4 year follow-up)
CL Item
54 Month Follow-up (54 month follow-up)
CL Item
5 Year Follow-up (5 year follow-up)
CL Item
66 Month Follow-up (66 month follow-up)
CL Item
6 Year Follow-up (6 year follow-up)
Item
This form is being filled out
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
CL Item
0 By Patient In Office (0 By patient in office)
CL Item
1 By Clinical Staff On Phone With Patient (1 By clinical staff on phone with patient)
CL Item
2 By Patient, Mailed To Office (2 By patient, mailed to office)
Item
I was bothered by things that don't usually bother me.
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25499 (NCI Thesaurus Property)
C0441471 (UMLS 2011AA Property)
C50535 (NCI Thesaurus Property)
C0234215 (UMLS 2011AA Property)
C14165 (NCI Thesaurus Property)
C0205307 (UMLS 2011AA Property)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C25515 (NCI Thesaurus ValueDomain)
C0439603 (UMLS 2011AA ValueDomain)
C0518214 (UMLS 2011AA ObjectClass)
C25499 (NCI Thesaurus Property)
C0441471 (UMLS 2011AA Property)
C50535 (NCI Thesaurus Property)
C0234215 (UMLS 2011AA Property)
C14165 (NCI Thesaurus Property)
C0205307 (UMLS 2011AA Property)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C25515 (NCI Thesaurus ValueDomain)
C0439603 (UMLS 2011AA ValueDomain)
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
Item
I had trouble keeping my mind on what I was doing.
text
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
Item
I felt depressed
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C2982 (NCI Thesaurus Property)
C0011570 (UMLS 2011AA Property)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C2982 (NCI Thesaurus Property)
C0011570 (UMLS 2011AA Property)
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
Item
I felt that everything I did was an effort.
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
Item
I felt hopeful about the future.
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
Item
I felt fearful.
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
CL Item
Rarely Or None Of The Time (less Than 1 Day) (Rarely or none of the time (less than 1 day))
CL Item
Some Of The Time (1-2 Days) (Some of the time (1-2 days))
CL Item
Occasion. (3-4 Days) (Occasion. (3-4 days))
CL Item
Most Of The Time (5-7 Days) (Most of the time (5-7 days))
Item Group
Everyday Problems During The Past Four Weeks
Item
Hot Flashes
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Headaches
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C34661 (NCI Thesaurus ObjectClass)
C0018681 (UMLS 2011AA ObjectClass)
C1522602 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C34661 (NCI Thesaurus ObjectClass)
C0018681 (UMLS 2011AA ObjectClass)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Difficulty with bladder control (at other times)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Difficulty with bladder control (at other times)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Vaginal discharge
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Vaginal bleeding or spotting
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Genital itching/irritation
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Vaginal dryness
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Pain with intercourse
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Breast pain
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Difficulty with breast skin
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Breast sensitivity/tenderness
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
General aches and pains
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Joint pains
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Muscle stiffness
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Weight loss
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C3445 (NCI Thesaurus ObjectClass)
C0043096 (UMLS 2011AA ObjectClass)
C1512698 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C3445 (NCI Thesaurus ObjectClass)
C0043096 (UMLS 2011AA ObjectClass)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Unhappy with appearance of my body
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Decreased appetite
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Forgetfulness
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Excitability
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Short temper
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Tendency to take naps; stay in bed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Night sweats
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Cold sweats
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Difficulty concentrating
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Easily distracted
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Trouble sleeping
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Early awakening
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Any other problems (Specify below)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Not At All (Not at all)
CL Item
Slightly (Slightly)
CL Item
Moderately (Moderately)
CL Item
Quite A Bit (Quite a bit)
CL Item
Extremely (Extremely)
Specifyotherproblems
Item
Specify other problems
text
Item
In general, would you say your health is (1)
text
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus ObjectClass)
C0018684 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus ObjectClass)
C0018684 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL Item
Excellent (Excellent)
CL Item
Very Good (Very good)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Fair (Fair)
CL Item
Poor (Poor)
Item
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf (2)
text
Code List
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf (2)
CL Item
Yes, Limited A Lot (Yes, Limited A lot)
CL Item
Yes, Limited A Little (Yes, Limited A little)
CL Item
No, Not Limited At All (No, not Limited At all)
Item
Climbing several flights of stairs (3)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL299704 (NCI Metathesaurus ObjectClass)
C17708 (NCI Thesaurus ObjectClass)
C0026606 (UMLS 2011AA ObjectClass)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL299704 (NCI Metathesaurus ObjectClass)
C17708 (NCI Thesaurus ObjectClass)
C0026606 (UMLS 2011AA ObjectClass)
CL Item
Yes, Limited A Lot (Yes, Limited A lot)
CL Item
Yes, Limited A Little (Yes, Limited A little)
CL Item
No, Not Limited At All (No, not Limited At all)
Item
Accomplished less than you would like. (6)
text
C25640 (NCI Thesaurus ObjectClass)
C0392756 (UMLS 2011AA ObjectClass)
C0033269 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0392756 (UMLS 2011AA ObjectClass)
C0033269 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
Item
Were limited in the kind of work or other activities. (5)
text
CL110648 (NCI Metathesaurus ObjectClass)
C0043227 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0043227 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
Item
Accomplished less than you would like. (6)
text
C25640 (NCI Thesaurus ObjectClass)
C0392756 (UMLS 2011AA ObjectClass)
C0033269 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0392756 (UMLS 2011AA ObjectClass)
C0033269 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
Item
Didn't do work or other activities as carefully as usual. (7)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
Item
During the past 4 weeks, how much did pain interfere with your normal work? (8. including both work outside the home and housework)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus ObjectClass)
C0030193 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0043227 (NCI Metathesaurus Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus ObjectClass)
C0030193 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0043227 (NCI Metathesaurus Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
Code List
During the past 4 weeks, how much did pain interfere with your normal work? (8. including both work outside the home and housework)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (A little bit)
CL Item
Moderately (Moderately)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Extremely (Extremely)
Item
Have you felt calm and peaceful? (9)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0035028 (NCI Metathesaurus Property)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0035028 (NCI Metathesaurus Property)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
Did you feel full of pep? (10)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0291944 (NCI Metathesaurus Property)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0291944 (NCI Metathesaurus Property)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
Did you have a lot of energy? (11)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C48058 (NCI Thesaurus Property)
C0542479 (UMLS 2011AA Property)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C48058 (NCI Thesaurus Property)
C0542479 (UMLS 2011AA Property)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
Did you feel worn out? (12)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3036 (NCI Thesaurus Property)
C0015672 (UMLS 2011AA Property)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3036 (NCI Thesaurus Property)
C0015672 (UMLS 2011AA Property)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
Did you feel tired? (13)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0023380 (NCI Metathesaurus Property)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0023380 (NCI Metathesaurus Property)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
Have you felt downhearted and blue? (14)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0026516 (NCI Metathesaurus Property)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0026516 (NCI Metathesaurus Property)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
A Good Bit Of The Time (A good bit of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities? (15. like visiting with friends, relatives, etc.)
text
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0037397 (NCI Metathesaurus ObjectClass)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
C0031809 (UMLS 2011AA Property)
C0037397 (NCI Metathesaurus ObjectClass)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
Code List
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities? (15. like visiting with friends, relatives, etc.)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
Some Of The Time (Some of the time)
CL Item
A Little Of The Time (A little of the time)
CL Item
None Of The Time (None of the time)
Item
Please score your overall quality of life as of today on an 11-point scale where 0 indicates being in the worst possible health and 10 indicates being in perfect health. (16)
text
Code List
Please score your overall quality of life as of today on an 11-point scale where 0 indicates being in the worst possible health and 10 indicates being in perfect health. (16)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Have you been sexually active during the past SIX MONTHS? (17)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Not A Problem (not a problem)
CL Item
A Little Problem (a little problem)
CL Item
A Definite Problem (a definite problem)
CL Item
A Serious Problem (a serious problem)
CL Item
Not A Problem (not a problem)
CL Item
A Little Problem (a little problem)
CL Item
A Definite Problem (a definite problem)
CL Item
A Serious Problem (a serious problem)
CL Item
Not A Problem (not a problem)
CL Item
A Little Problem (a little problem)
CL Item
A Definite Problem (a definite problem)
CL Item
A Serious Problem (a serious problem)
CL Item
Not A Problem (not a problem)
CL Item
A Little Problem (a little problem)
CL Item
A Definite Problem (a definite problem)
CL Item
A Serious Problem (a serious problem)