ID

620

Beschreibung

RTOG 0825: QOL M.D. Anderson Symptom Inventory 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=5BABD9A9-3DF8-0152-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5BABD9A9-3DF8-0152-E044-0003BA3F9857

Stichworte

Versionen (4)
  1. 26.08.12 26.08.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
  3. 09.01.15 09.01.15 - Martin Dugas
  4. 20.09.21 20.09.21 -
Hochgeladen am

26. August 2012

DOI

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Lizenz

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Brain and Central Nervous System Tumors NCT00884741 On-Study - RTOG 0825: QOL M.D. Anderson Symptom Inventory - 2800871v1.0

Englisch

INSTRUCTIONS: This sheet is the cover page used for the submission of the QOL questionnaires. It needs to be completed by the medical staff (nurse, data manager, physician, etc.) and should be submitted with each questionnaire

1 Formulare  
Unnamed Module 1
Beschreibung

Unnamed Module 1

RTOG Study No.
Beschreibung

ProtocolRTOGIdentifierNumber

Datentyp

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 #
Beschreibung

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C19778
UMLS 2011AA ObjectClass
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C49152
UMLS 2011AA Property
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Beschreibung

InstitutionName

Datentyp

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.
Beschreibung

InstitutionIdentifierNumber

Datentyp

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
Patient Initials
Beschreibung

PatientInitialsName

Datentyp

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
RTOG Patient ID
Beschreibung

PatientRadiationTherapyOncologyGroupIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Amended Data
Beschreibung

DataAmendedInd-3

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unamed Module 2
Beschreibung

Unamed Module 2

Time point of this assessment (please check box that applies to this assessment)
Beschreibung

AssessmentPeriodType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Was patient questionnaire completed
Beschreibung

PatientQuestionnaireCompleteInd-2

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
Date Questionnaire Completed (MM DD YYYY)
Beschreibung

QualityofLifeCompleteAssessmentDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25367
Reason Questionnaire was not Completed
Beschreibung

PatientIncompleteQuestionnaireReason

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
Patient refused for other reason, specify
Beschreibung

PatientRefuseIncompleteQuestionnaireSpecify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C49161
UMLS 2011AA Property
C1705116
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Other reason, specify
Beschreibung

PatientIncompleteQuestionnaireOtherSpecify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C17649
UMLS 2011AA ValueDomain
C0205394
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
Specify method of completion
Beschreibung

PatientQuestionnaireCompleteMethodofCollectionType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
Did the patient require any assistance in completing the questionnaire?
Beschreibung

PatientQuestionnaireAssistanceInd

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
Specify the person who assisted the patient
Beschreibung

PatientQuestionnaireAssistancePersonCategory

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25190
UMLS 2011AA ValueDomain
C0027361
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
Other, specify
Beschreibung

PatientQuestionnaireAssistancePersonSpecify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C25190
UMLS 2011AA ValueDomain
C0027361
Extent of assistance given
Beschreibung

PatientQuestionnaireAssistanceType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
Combination of above, specify
Beschreibung

PatientQuestionnaireAssistanceCombinedSpecify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17048
UMLS 2011AA Property
C0034394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C25454
UMLS 2011AA ValueDomain
C0205195
Comments
Beschreibung

ResearchCommentsText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Signature of Person Completing This Form
Beschreibung

ResponsiblePersonSignatureText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Form Completion Date, Original (MM DD YYYY)
Beschreibung

FormOriginalCompleteDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25604
UMLS 2011AA Property
C0205313
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
M.d. Anderson Symptom Inventory (mdasi-bt)
Beschreibung

M.d. Anderson Symptom Inventory (mdasi-bt)

Your pain at its worst
Beschreibung

PatientWorstPainSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus Property
C25719
UMLS 2011AA Property
C1522166
Your fatigue at its worst
Beschreibung

PatientFatigueAssessmentSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C3036
UMLS 2011AA Property
C0015672
Your nausea at its worst
Beschreibung

PatientNauseaAssessmentSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C3258
UMLS 2011AA Property
C0027497
Your disturbed sleep at its worst
Beschreibung

PatientSleepDifficultyAssessmentSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C73425
UMLS 2011AA Property
C0037313
NCI Thesaurus Property
C62189
UMLS 2011AA Property
C1299586
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your feeling of being distressed at its worst
Beschreibung

PatientDistressSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C37942
UMLS 2011AA Property
C0231303
Your shortness of breath at its worst
Beschreibung

PatientDyspneaAssessmentSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C2998
UMLS 2011AA Property
C0013404
Your problem with remembering things at its worst
Beschreibung

NeurologicalEvaluationMemorySymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C25214
UMLS 2011AA ObjectClass
C0220825
NCI Thesaurus ObjectClass
C25262
UMLS 2011AA ObjectClass
C0205494
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C37992
UMLS 2011AA Property
C0025260
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your problem with lack of appetite at its worst
Beschreibung

PatientAppetiteLossSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25559
UMLS 2011AA Property
C1517945
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C25152
UMLS 2011AA Property
C0003618
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your feeling drowsy at its worst
Beschreibung

PatientSomnolenceSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C26754
UMLS 2011AA Property
C2830004
Your having a dry mouth at its worst
Beschreibung

PatientDryMouthAssessmentSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C26917
UMLS 2011AA Property
C0043352
Your feeling sad at its worst
Beschreibung

PatientDepressionAssessmentSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C2982
UMLS 2011AA Property
C0011570
Your vomiting at its worst
Beschreibung

PatientVomitingSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3442
UMLS 2011AA Property
C0042963
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
Your numbness or tingling at its worst
Beschreibung

PatientNumbnessTinglingSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C34857
UMLS 2011AA Property
C0028643
NCI Thesaurus Property
C50771
UMLS 2011AA Property
C2242996
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your weakness on one side of body at its worst
Beschreibung

BrainQualityofLifeWeaknessSideBodyAssessmentSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12439
UMLS 2011AA ObjectClass
C0006104
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C13041
UMLS 2011AA Property
C1268086
NCI Thesaurus Property
C25306
UMLS 2011AA Property
C0441987
NCI Thesaurus Property
C50809
UMLS 2011AA Property
C1883552
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your difficulty understanding at its worst
Beschreibung

PatientDifficultyComprehensionSymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C62189
UMLS 2011AA Property
C1299586
NCI Metathesaurus Property
C0162340
Your difficulty speaking at its worst
Beschreibung

BrainQualityofLifeDifficultySpeechAssessmentSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C12439
UMLS 2011AA ObjectClass
C0006104
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C38025
UMLS 2011AA Property
C0037817
NCI Thesaurus Property
C62189
UMLS 2011AA Property
C1299586
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your seizures at its worst
Beschreibung

NeurologicalEvaluationSeizureSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C25214
UMLS 2011AA ObjectClass
C0220825
NCI Thesaurus ObjectClass
C25262
UMLS 2011AA ObjectClass
C0205494
NCI Thesaurus Property
C2962
UMLS 2011AA Property
C0036572
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your difficulty concentrating at its worst
Beschreibung

Quality-of-LifeAssessmentPatientDifficultyAttentionConcentrationSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C62189
UMLS 2011AA Property
C1299586
NCI Thesaurus Property
C41209
UMLS 2011AA Property
C0004268
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your vision at its worst
Beschreibung

PatientDifficultyVisionSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C62189
UMLS 2011AA Property
C1299586
NCI Metathesaurus Property
C0042789
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your change in appearance at its worst
Beschreibung

PatientAppearanceDeteriorationSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25377
UMLS 2011AA Property
C0700364
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C25751
UMLS 2011AA Property
C0868945
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your change in bowel pattern at its worst
Beschreibung

PatientDiarrheaConstipationSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C37930
UMLS 2011AA Property
C0009806
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C2987
UMLS 2011AA Property
C0011991
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Your irritability at its worst
Beschreibung

PatientIrritabilitySymptomScale

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C50623
UMLS 2011AA Property
C0022107
Part Ii
Beschreibung

Part Ii

General activity
Beschreibung

PatientGeneralizedActivityInterferenceSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C43431
UMLS 2011AA Property
C0441655
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C63764
UMLS 2011AA Property
C0205246
NCI Thesaurus Property
C72886
UMLS 2011AA Property
C2346501
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Mood
Beschreibung

PatientMoodInterferenceSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C72886
UMLS 2011AA Property
C2346501
NCI Thesaurus Property
C72883
UMLS 2011AA Property
C0026516
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Work
Beschreibung

PatientWorkInterferenceSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C74299
UMLS 2011AA Property
C0043227
NCI Thesaurus Property
C72886
UMLS 2011AA Property
C2346501
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Relations with other people
Beschreibung

PatientRelationshipInterferenceSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25648
UMLS 2011AA Property
C0439849
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C72886
UMLS 2011AA Property
C2346501
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Walking
Beschreibung

PatientWalkingInterferenceSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C73554
UMLS 2011AA Property
C0080331
NCI Thesaurus Property
C72886
UMLS 2011AA Property
C2346501
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Enjoyment of life
Beschreibung

PatientLifeJoyInterferenceSymptomScale

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C37987
UMLS 2011AA Property
C0376558
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Thesaurus Property
C77961
UMLS 2011AA Property
C0018592
NCI Thesaurus Property
C72886
UMLS 2011AA Property
C2346501
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
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Ähnliche Modelle

INSTRUCTIONS: This sheet is the cover page used for the submission of the QOL questionnaires. It needs to be completed by the medical staff (nurse, data manager, physician, etc.) and should be submitted with each questionnaire

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed Module 1
ProtocolRTOGIdentifierNumber
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)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass)
C1514695 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property)
C1706256 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
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
Patient 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)
PatientRadiationTherapyOncologyGroupIdentifierNumber
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Amended Data
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended Data
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unamed Module 2
Item
Time point of this assessment (please check box that applies to this assessment)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.2
Code List
Time point of this assessment (please check box that applies to this assessment)
CL Item
Registration (Registration)
C25646 (NCI Thesaurus)
C1514821 (UMLS 2011AA)
CL Item
Week 6 (week 6)
CL Item
Week 10 (Week 10)
CL Item
Week 22 (Week 22)
CL Item
Week 34 (Week 34)
CL Item
Week 46 (Week 46)
CL Item
Week 46 (Week 62)
CL Item
Other Followup (Other follow-ups)
Item
Was patient questionnaire completed
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
CL.3
Code List
Was patient questionnaire completed
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
Item
Reason Questionnaire was not Completed
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
CL.4
Code List
Reason Questionnaire was not Completed
CL Item
Patient Refused Due To Illness (Patient refused due to illness)
CL Item
Patient Unable To Be Contacted (Patient unable to be contacted)
CL Item
Questionnaire Not Completed Due To Institutional Error (Questionnaire not completed due to institutional error)
CL Item
Tool Not Availalble In Patient's Language (Tool not available in patient's language)
CL Item
Patient Refused For Other Reason (Patient refused for other reason)
CL Item
Other Reason (Other reason)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientRefuseIncompleteQuestionnaireSpecify
Item
Patient refused for other reason, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C49161 (NCI Thesaurus Property)
C1705116 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
PatientIncompleteQuestionnaireOtherSpecify
Item
Other reason, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain)
C0205394 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
Item
Specify method of completion
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
CL.5
Code List
Specify method of completion
CL Item
At Appointment (At appointment)
CL Item
By Mail (By mail)
CL Item
By Telephone (By telephone)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Did the patient require any assistance in completing the questionnaire?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
CL.6
Code List
Did the patient require any assistance in completing the questionnaire?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown If Assistance Given (Unknown if assistance given)
Item
Specify the person who assisted the patient
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25190 (NCI Thesaurus ValueDomain)
C0027361 (UMLS 2011AA ValueDomain)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
CL.7
Code List
Specify the person who assisted the patient
CL Item
Staff Member (Staff member)
CL Item
Family (Family)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
PatientQuestionnaireAssistancePersonSpecify
Item
Other, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ValueDomain)
C0027361 (UMLS 2011AA ValueDomain)
Item
Extent of assistance given
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
CL.8
Code List
Extent of assistance given
CL Item
Read Items To Patient (Read items to patient)
CL Item
Marked Items Per Patient's Response (Marked items per patient's response)
CL Item
Combination Of Above (Combination of above)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientQuestionnaireAssistanceCombinedSpecify
Item
Combination of above, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus Property)
C0034394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25454 (NCI Thesaurus ValueDomain)
C0205195 (UMLS 2011AA ValueDomain)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
ResponsiblePersonSignatureText
Item
Signature of Person Completing This Form
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (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)
FormOriginalCompleteDate
Item
Form Completion Date, Original (MM DD YYYY)
date
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
Item Group
M.d. Anderson Symptom Inventory (mdasi-bt)
Item
Your pain at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25719 (NCI Thesaurus Property)
C1522166 (UMLS 2011AA Property)
CL.9
Code List
Your pain at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your fatigue at its worst
double
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)
CL.10
Code List
Your fatigue at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your nausea at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3258 (NCI Thesaurus Property)
C0027497 (UMLS 2011AA Property)
CL.11
Code List
Your nausea at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your disturbed sleep at its worst
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C73425 (NCI Thesaurus Property)
C0037313 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.12
Code List
Your disturbed sleep at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your feeling of being distressed at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C37942 (NCI Thesaurus Property)
C0231303 (UMLS 2011AA Property)
CL.13
Code List
Your feeling of being distressed at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your shortness of breath at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C2998 (NCI Thesaurus Property)
C0013404 (UMLS 2011AA Property)
CL.14
Code List
Your shortness of breath at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your problem with remembering things at its worst
double
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS 2011AA ObjectClass)
C25262 (NCI Thesaurus ObjectClass)
C0205494 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C37992 (NCI Thesaurus Property)
C0025260 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.15
Code List
Your problem with remembering things at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your problem with lack of appetite at its worst
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25559 (NCI Thesaurus Property)
C1517945 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C25152 (NCI Thesaurus Property)
C0003618 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.16
Code List
Your problem with lack of appetite at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your feeling drowsy at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C26754 (NCI Thesaurus Property)
C2830004 (UMLS 2011AA Property)
CL.17
Code List
Your feeling drowsy at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your having a dry mouth at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C26917 (NCI Thesaurus Property)
C0043352 (UMLS 2011AA Property)
CL.18
Code List
Your having a dry mouth at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your feeling sad at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C2982 (NCI Thesaurus Property)
C0011570 (UMLS 2011AA Property)
CL.19
Code List
Your feeling sad at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your vomiting at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3442 (NCI Thesaurus Property)
C0042963 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL.20
Code List
Your vomiting at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your numbness or tingling at its worst
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C34857 (NCI Thesaurus Property)
C0028643 (UMLS 2011AA Property)
C50771 (NCI Thesaurus Property)
C2242996 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.21
Code List
Your numbness or tingling at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your weakness on one side of body at its worst
double
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C13041 (NCI Thesaurus Property)
C1268086 (UMLS 2011AA Property)
C25306 (NCI Thesaurus Property)
C0441987 (UMLS 2011AA Property)
C50809 (NCI Thesaurus Property)
C1883552 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.22
Code List
Your weakness on one side of body at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your difficulty understanding at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C0162340 (NCI Metathesaurus Property)
CL.23
Code List
Your difficulty understanding at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your difficulty speaking at its worst
double
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C38025 (NCI Thesaurus Property)
C0037817 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.24
Code List
Your difficulty speaking at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your seizures at its worst
double
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS 2011AA ObjectClass)
C25262 (NCI Thesaurus ObjectClass)
C0205494 (UMLS 2011AA ObjectClass)
C2962 (NCI Thesaurus Property)
C0036572 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.25
Code List
Your seizures at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your difficulty concentrating at its worst
double
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C41209 (NCI Thesaurus Property)
C0004268 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.26
Code List
Your difficulty concentrating at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your vision at its worst
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C0042789 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.27
Code List
Your vision at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your change in appearance at its worst
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25377 (NCI Thesaurus Property)
C0700364 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C25751 (NCI Thesaurus Property)
C0868945 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.28
Code List
Your change in appearance at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your change in bowel pattern at its worst
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C37930 (NCI Thesaurus Property)
C0009806 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C2987 (NCI Thesaurus Property)
C0011991 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.29
Code List
Your change in bowel pattern at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Your irritability at its worst
double
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C50623 (NCI Thesaurus Property)
C0022107 (UMLS 2011AA Property)
CL.30
Code List
Your irritability at its worst
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item Group
Part Ii
Item
General activity
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C43431 (NCI Thesaurus Property)
C0441655 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C63764 (NCI Thesaurus Property)
C0205246 (UMLS 2011AA Property)
C72886 (NCI Thesaurus Property)
C2346501 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.31
Code List
General activity
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Mood
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C72886 (NCI Thesaurus Property)
C2346501 (UMLS 2011AA Property)
C72883 (NCI Thesaurus Property)
C0026516 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.32
Code List
Mood
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Work
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C74299 (NCI Thesaurus Property)
C0043227 (UMLS 2011AA Property)
C72886 (NCI Thesaurus Property)
C2346501 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.33
Code List
Work
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Relations with other people
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25648 (NCI Thesaurus Property)
C0439849 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C72886 (NCI Thesaurus Property)
C2346501 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.34
Code List
Relations with other people
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Walking
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C73554 (NCI Thesaurus Property)
C0080331 (UMLS 2011AA Property)
C72886 (NCI Thesaurus Property)
C2346501 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.35
Code List
Walking
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
Item
Enjoyment of life
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C37987 (NCI Thesaurus Property)
C0376558 (UMLS 2011AA Property)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C77961 (NCI Thesaurus Property)
C0018592 (UMLS 2011AA Property)
C72886 (NCI Thesaurus Property)
C2346501 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.36
Code List
Enjoyment of life
CL Item
Whole Number (0)
CL Item
Whole Number (1)
CL Item
Whole Number (10)
CL Item
Whole Number (2)
CL Item
Whole Number (3)
CL Item
Whole Number (4)
CL Item
Whole Number (5)
CL Item
Whole Number (6)
CL Item
Whole Number (7)
CL Item
Whole Number (8)
CL Item
Whole Number (9)
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