ID

6220

Description

CALGB : 49907 YOUR HEALTH (FORM C) Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Keywords

Versions (3)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 3/20/15 3/20/15 - Martin Dugas
  3. 9/20/21 9/20/21 -
Uploaded on

December 18, 2014

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer NCT00024102 Quality of Life - CALGB : 49907 YOUR HEALTH (FORM C) - 2045191v3.0

English

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.

1 forms  
Unnamed1
Description

Unnamed1

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (Medicine)
Description

DateCompleted

Data type

date

Amended data?
Description

Amendeddata?

Data type

text

Unnamed2
Description

Unnamed2

Patient's Name
Description

Patient'sName

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Data type

text

Unnamed3
Description

Unnamed3

Responsible CRA
Description

ResponsibleCRA

Data type

text

Assessment Number (1. Your General Health)
Description

AssessmentNumber

Data type

double

Unnamed4
Description

Unnamed4

Other cancers or leukemia (a.)
Description

Othercancersorleukemia

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Other cancers or leukemia (b.)
Description

Howmuchdoesitinterferewithyouractivities:Othercancersorleukemia

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Arthritis, rheumatism, or other connective tissue disorders (b.)
Description

Arthritis,rheumatism,orotherconnectivetissuedisorders

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
Description

Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Glaucoma (c.)
Description

Glaucoma

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Glaucoma (d.)
Description

Howmuchdoesitinterferewithyouractivities:Glaucoma

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Emphysema or Chronic Bronchitis (d.)
Description

EmphysemaorChronicBronchitis

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
Description

Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
High Blood Pressure (e.)
Description

HighBloodPressure

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: High Blood Pressure (f.)
Description

Howmuchdoesitinterferewithyouractivities:HighBloodPressure

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Heart disease (f.)
Description

Heartdisease

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Heart disease (g.)
Description

Howmuchdoesitinterferewithyouractivities:Heartdisease

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Circulation trouble in arms or legs (g.)
Description

Circulationtroubleinarmsorlegs

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
Description

Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Diabetes (h.)
Description

Diabetes

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Diabetes (i.)
Description

Howmuchdoesitinterferewithyouractivities:Diabetes

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Stomach or intestinal disorders (i.)
Description

Stomachorintestinaldisorders

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
Description

Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Osteoporosis (j.)
Description

Osteoporosis

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Osteoporosis (k.)
Description

Howmuchdoesitinterferewithyouractivities:Osteoporosis

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Chronic Liver or Kidney Disease (k.)
Description

ChronicLiverorKidneyDisease

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Description

Howmuchdoesitinterferewithyouractivities:ChronicLiverorKidneyDisease

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Stroke (l.)
Description

Stroke

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Stroke (m.)
Description

Howmuchdoesitinterferewithyouractivities:Stroke

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Depression (m.)
Description

Depression

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
How much does it interfere with your activities: Depression
Description

Howmuchdoesitinterferewithyouractivities:Depression

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Unnamed5
Description

Unnamed5

Patient's Name
Description

Patient'sName

Data type

text

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (Medicine)
Description

DateCompleted

Data type

date

Unnamed6
Description

Unnamed6

How is your eyesight (with glasses or contacts)? (mark one with an X)
Description

Howisyoureyesight(withglassesorcontacts)?

Data type

text

If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
Description

Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
How if your hearing (with a hearing aid, if needed)? (mark one with an X)
Description

Howifyourhearing(withahearingaid,ifneeded)?

Data type

text

If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Description

Iffair,poorortotallydeaf,howmuchdoesthisinterferewithyouractivities?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
Description

Doyouhaveanyotherphysicalproblemsorillnesses(thanlistedinquestion1-3)atthepresenttimethatseriouslyaffectyourhealth?

Data type

text

Yes, specify (other physical problems or illnesses at the present time that seriously affect your health) (If Yes)
Description

Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)

Data type

text

how much does this interfere with your activities? (mark one with an X)
Description

howmuchdoesthisinterferewithyouractivities?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
Description

Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?

Data type

text

During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
Description

Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?

Data type

text

How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Description

Howmanydaysinthepast3monthswereyouinahospitalforphysicalhealthproblems?

Data type

text

Unnamed7
Description

Unnamed7

Patient's Name
Description

Patient'sName

Data type

text

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (Medicine)
Description

DateCompleted

Data type

date

Unnamed8
Description

Unnamed8

Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
Description

Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
What type of counseling or treatment did you receive? (mark all that apply with an X)
Description

Whattypeofcounselingortreatmentdidyoureceive?

Data type

text

Other, specify (type of counseling or treatment received) (8c.)
Description

Other,specify(typeofcounselingortreatmentreceived)

Data type

text

Check any of these services that you are still receiving (mark all that apply with an X)
Description

Checkanyoftheseservicesthatyouarestillreceiving

Data type

text

Other, specify (services that you are still receiving) (Only For ALL FOLLOW-UP INTERVIEWS: Questions 9-10)
Description

Other,specify(servicesthatyouarestillreceiving)

Data type

text

Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
Description

Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Description

Whattypeofcounselingortreatmentdidyoureceive?(follow-up)

Data type

text

Other, specify (type of counseling or treatment received; follow-up)
Description

Other,specify(typeofcounselingortreatmentreceived;follow-up)

Data type

text

Unnamed9
Description

Unnamed9

Patient's Name
Description

Patient'sName

Data type

text

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (Medicine)
Description

DateCompleted

Data type

date

Unnamed10
Description

Unnamed10

Check any of these services that you are still receiving (follow-up) (mark all that apply with an X)
Description

Checkanyoftheseservicesthatyouarestillreceiving(follow-up)

Data type

text

Other, specify (services that you are still receiving; follow-up) (MEDICATIONS FOR PHYSICAL PROBLEMS OF CANCER TREATMENT)
Description

Other,specify(servicesthatyouarestillreceiving;follow-up)

Data type

text

Medicine to treat nausea and/or vomiting
Description

Medicinetotreatnauseaand/orvomiting

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine to treat diarrhea
Description

Medicinetotreatdiarrhea

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine to reduce feeling very tired [fatigue]
Description

Medicinetoreducefeelingverytired[fatigue]

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine to reduce swelling in hands or feet
Description

Medicinetoreduceswellinginhandsorfeet

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine or cream to treat mouth sores
Description

Medicineorcreamtotreatmouthsores

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Pain medicine for hands or feet
Description

Painmedicineforhandsorfeet

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Description

Medicineorcreamtotreatskinchanges(e.g.redness,peeling)inhandsorfeet

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Other, specify
Description

Other,specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Other, specify (medication to treat any physical problems you have had from your cancer treatment)
Description

Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)

Data type

text

Unnamed11
Description

Unnamed11

Patient's Name
Description

Patient'sName

Data type

text

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (Medicine)
Description

DateCompleted

Data type

date

Unnamed12
Description

Unnamed12

Arthritis medicine (If Taken, How Often?)
Description

Arthritismedicine

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Arthritis medicine (b.)
Description

IfTaken,HowOften:Arthritismedicine

Data type

text

Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Description

Prescriptionpainkiller

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Description

IfTaken,HowOften:Prescriptionpainkiller

Data type

text

Over-the counter pain killers (c.)
Description

Over-thecounterpainkillers

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
Description

IfTaken,HowOften:Over-thecounterpainkillers

Data type

text

High blood pressure medicine (d.)
Description

Highbloodpressuremedicine

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: High blood pressure medicine (e.)
Description

IfTaken,HowOften:Highbloodpressuremedicine

Data type

text

Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
Description

Pillstomakeyoulosewaterorsalt

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Pills to make you lose water or salt (f.)
Description

IfTaken,HowOften:Pillstomakeyoulosewaterorsalt

Data type

text

Digoxin pills for the heart (Lanoxin)
Description

Digoxinpillsfortheheart

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Description

IfTaken,HowOften:Digoxinpillsfortheheart

Data type

text

Nitroglycerin for chest pain (tablets or patches)
Description

Nitroglycerinforchestpain

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Description

IfTaken,HowOften:Nitroglycerinforchestpain

Data type

text

Blood thinner medicine (anticoagulants)
Description

Bloodthinnermedicine

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Blood thinner medicine (anticoagulants)
Description

IfTaken,HowOften:Bloodthinnermedicine

Data type

text

Medicine to improve circulation (i.)
Description

Medicinetoimprovecirculation

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Medicine to improve circulation (j.)
Description

IfTaken,HowOften:Medicinetoimprovecirculation

Data type

text

Insulin injections for diabetes (j.)
Description

Insulininjectionsfordiabetes

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Insulin injections for diabetes (k.)
Description

IfTaken,HowOften:Insulininjectionsfordiabetes

Data type

text

Pills for diabetes (k.)
Description

Pillsfordiabetes

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Pills for diabetes (l.)
Description

IfTaken,HowOften:Pillsfordiabetes

Data type

text

Ulcer medicine (l.)
Description

Ulcermedicine

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Ulcer medicine (m.)
Description

IfTaken,HowOften:Ulcermedicine

Data type

text

Asthma medicines (m.)
Description

Asthmamedicines

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Asthma medicines (n.)
Description

IfTaken,HowOften:Asthmamedicines

Data type

text

Seizure medicines (like Dilantin)
Description

Seizuremedicines

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Seizure medicines (like Dilantin)
Description

IfTaken,HowOften:Seizuremedicines

Data type

text

Unnamed13
Description

Unnamed13

Patient's Name
Description

Patient'sName

Data type

text

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (Medicine)
Description

DateCompleted

Data type

date

Unnamed14
Description

Unnamed14

Thyroid pills (If Taken, How Often?)
Description

Thyroidpills

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Thyroid pills (p.)
Description

IfTaken,HowOften:Thyroidpills

Data type

text

Cortisone pills or injections (p.)
Description

Cortisonepillsorinjections

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Cortisone pills or injections (q.)
Description

IfTaken,HowOften:Cortisonepillsorinjections

Data type

text

Antibiotics (q.)
Description

Antibiotics

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Antibiotics (r.)
Description

IfTaken,HowOften:Antibiotics

Data type

text

Tranquilizers or medicine for your nerves (r.)
Description

Tranquilizersormedicineforyournerves

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Description

IfTaken,HowOften:Tranquilizersormedicineforyournerves

Data type

text

Prescription sleeping pills (s.)
Description

Prescriptionsleepingpills

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Prescription sleeping pills (t.)
Description

IfTaken,HowOften:Prescriptionsleepingpills

Data type

text

Over-the-counter pills to help you sleep (t.)
Description

Over-the-counterpillstohelpyousleep

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Description

IfTaken,HowOften:Over-the-counterpillstohelpyousleep

Data type

text

Hormones (male or female)
Description

Hormones

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Hormones (v.)
Description

IfTaken,HowOften:Hormones

Data type

text

Allergy medicines (v.)
Description

Allergymedicines

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Allergy medicines (w.)
Description

IfTaken,HowOften:Allergymedicines

Data type

text

Laxatives (w.)
Description

Laxatives

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Laxatives (x.)
Description

IfTaken,HowOften:Laxatives

Data type

text

Eye drops for glaucoma (x.)
Description

Eyedropsforglaucoma

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Eye drops for glaucoma (y.)
Description

IfTaken,HowOften:Eyedropsforglaucoma

Data type

text

Calcium tablets (y.)
Description

Calciumtablets

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Calcium tablets (z.)
Description

IfTaken,HowOften:Calciumtablets

Data type

text

Vitamins and/or minerals (other than calcium)
Description

Vitaminsand/orminerals

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Description

IfTaken,HowOften:Vitaminsand/orminerals

Data type

text

Herbal medicines (aa.)
Description

Herbalmedicines

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Herbal medicines (12.)
Description

IfTaken,HowOften:Herbalmedicines

Data type

text

Unnamed15
Description

Unnamed15

Have you taken any other medicines in the past month?
Description

Haveyoutakenanyothermedicinesinthepastmonth?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Name of Medicine
Description

NameofMedicine

Data type

text

If Taken, How Often?
Description

IfTaken,HowOften?

Data type

text

Ccrr Module For Calgb : 49907 Your Health (form C)
Description

Ccrr Module For Calgb : 49907 Your Health (form C)

Back to the top of the page

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.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
Unnamed3
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1. Your General Health)
double
Item Group
Unnamed4
Item
Other cancers or leukemia (a.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.2
Code List
Other cancers or leukemia (a.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Other cancers or leukemia (b.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.3
Code List
How much does it interfere with your activities: Other cancers or leukemia (b.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Arthritis, rheumatism, or other connective tissue disorders (b.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.4
Code List
Arthritis, rheumatism, or other connective tissue disorders (b.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.5
Code List
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Glaucoma (c.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.6
Code List
Glaucoma (c.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Glaucoma (d.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.7
Code List
How much does it interfere with your activities: Glaucoma (d.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Emphysema or Chronic Bronchitis (d.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.8
Code List
Emphysema or Chronic Bronchitis (d.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.9
Code List
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
High Blood Pressure (e.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.10
Code List
High Blood Pressure (e.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: High Blood Pressure (f.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.11
Code List
How much does it interfere with your activities: High Blood Pressure (f.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Heart disease (f.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.12
Code List
Heart disease (f.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Heart disease (g.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.13
Code List
How much does it interfere with your activities: Heart disease (g.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Circulation trouble in arms or legs (g.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.14
Code List
Circulation trouble in arms or legs (g.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.15
Code List
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Diabetes (h.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.16
Code List
Diabetes (h.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Diabetes (i.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.17
Code List
How much does it interfere with your activities: Diabetes (i.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Stomach or intestinal disorders (i.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.18
Code List
Stomach or intestinal disorders (i.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.19
Code List
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Osteoporosis (j.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.20
Code List
Osteoporosis (j.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Osteoporosis (k.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.21
Code List
How much does it interfere with your activities: Osteoporosis (k.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Chronic Liver or Kidney Disease (k.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.22
Code List
Chronic Liver or Kidney Disease (k.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.23
Code List
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Stroke (l.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.24
Code List
Stroke (l.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Stroke (m.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.25
Code List
How much does it interfere with your activities: Stroke (m.)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item
Depression (m.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.26
Code List
Depression (m.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How much does it interfere with your activities: Depression
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.27
Code List
How much does it interfere with your activities: Depression
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A Great Deal)
Item Group
Unnamed5
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Item Group
Unnamed6
Item
How is your eyesight (with glasses or contacts)? (mark one with an X)
text
CL.28
Code List
How is your eyesight (with glasses or contacts)? (mark one with an X)
CL Item
Excellent (Excellent)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Fair (Fair)
CL Item
Poor (Poor)
CL Item
Totally Blind (Totally blind)
Item
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.29
Code List
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A great deal)
Item
How if your hearing (with a hearing aid, if needed)? (mark one with an X)
text
CL.30
Code List
How if your hearing (with a hearing aid, if needed)? (mark one with an X)
CL Item
Excellent (Excellent)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
CL Item
Fair (Fair)
CL Item
Poor (Poor)
CL Item
Totally Deaf (Totally deaf)
Item
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.31
Code List
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A great deal)
Item
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
text
CL.32
Code List
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Specify (Yes, specify)
Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)
Item
Yes, specify (other physical problems or illnesses at the present time that seriously affect your health) (If Yes)
text
Item
how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.33
Code List
how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
A Great Deal (A great deal)
Item
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
text
CL.34
Code List
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 To 2 (1 to 2)
CL Item
3 To 5 (3 to 5)
CL Item
6 To 9 (6 to 9)
CL Item
10 To 14 (10 to 14)
CL Item
15 Or More (15 or more)
CL Item
Don't Know (Don't know)
Item
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
text
CL.35
Code List
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
A Week Or Less (A week or less)
CL Item
More Than A Week, But Less Than A Month (More than a week, but less than a month)
CL Item
One To Two Months (One to two months)
CL Item
Three Months (Three months)
Item
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
text
CL.36
Code List
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 To 2 (1 to 2)
CL Item
3 To 5 (3 to 5)
CL Item
6 To 9 (6 to 9)
CL Item
10 To 14 (10 to 14)
CL Item
15 Or More (15 or more)
CL Item
Don't Know (Don't know)
Item Group
Unnamed7
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Item Group
Unnamed8
Item
Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.37
Code List
Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
What type of counseling or treatment did you receive? (mark all that apply with an X)
text
CL.38
Code List
What type of counseling or treatment did you receive? (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other,specify(typeofcounselingortreatmentreceived)
Item
Other, specify (type of counseling or treatment received) (8c.)
text
Item
Check any of these services that you are still receiving (mark all that apply with an X)
text
CL.39
Code List
Check any of these services that you are still receiving (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other,specify(servicesthatyouarestillreceiving)
Item
Other, specify (services that you are still receiving) (Only For ALL FOLLOW-UP INTERVIEWS: Questions 9-10)
text
Item
Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.40
Code List
Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
text
CL.41
Code List
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other,specify(typeofcounselingortreatmentreceived;follow-up)
Item
Other, specify (type of counseling or treatment received; follow-up)
text
Item Group
Unnamed9
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Item Group
Unnamed10
Item
Check any of these services that you are still receiving (follow-up) (mark all that apply with an X)
text
CL.42
Code List
Check any of these services that you are still receiving (follow-up) (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other,specify(servicesthatyouarestillreceiving;follow-up)
Item
Other, specify (services that you are still receiving; follow-up) (MEDICATIONS FOR PHYSICAL PROBLEMS OF CANCER TREATMENT)
text
Item
Medicine to treat nausea and/or vomiting
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.43
Code List
Medicine to treat nausea and/or vomiting
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Medicine to treat diarrhea
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.44
Code List
Medicine to treat diarrhea
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Medicine to reduce feeling very tired [fatigue]
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.45
Code List
Medicine to reduce feeling very tired [fatigue]
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Medicine to reduce swelling in hands or feet
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.46
Code List
Medicine to reduce swelling in hands or feet
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Medicine or cream to treat mouth sores
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.47
Code List
Medicine or cream to treat mouth sores
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Pain medicine for hands or feet
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.48
Code List
Pain medicine for hands or feet
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.49
Code List
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Other, specify
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.50
Code List
Other, specify
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)
Item
Other, specify (medication to treat any physical problems you have had from your cancer treatment)
text
Item Group
Unnamed11
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Item Group
Unnamed12
Item
Arthritis medicine (If Taken, How Often?)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.51
Code List
Arthritis medicine (If Taken, How Often?)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Arthritis medicine (b.)
text
CL.52
Code List
If Taken, How Often: Arthritis medicine (b.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.53
Code List
Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
text
CL.54
Code List
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Over-the counter pain killers (c.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.55
Code List
Over-the counter pain killers (c.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
text
CL.56
Code List
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
High blood pressure medicine (d.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.57
Code List
High blood pressure medicine (d.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: High blood pressure medicine (e.)
text
CL.58
Code List
If Taken, How Often: High blood pressure medicine (e.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.59
Code List
Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Pills to make you lose water or salt (f.)
text
CL.60
Code List
If Taken, How Often: Pills to make you lose water or salt (f.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Digoxin pills for the heart (Lanoxin)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.61
Code List
Digoxin pills for the heart (Lanoxin)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
text
CL.62
Code List
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Nitroglycerin for chest pain (tablets or patches)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.63
Code List
Nitroglycerin for chest pain (tablets or patches)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
text
CL.64
Code List
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Blood thinner medicine (anticoagulants)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.65
Code List
Blood thinner medicine (anticoagulants)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Blood thinner medicine (anticoagulants)
text
CL.66
Code List
If Taken, How Often: Blood thinner medicine (anticoagulants)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Medicine to improve circulation (i.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.67
Code List
Medicine to improve circulation (i.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Medicine to improve circulation (j.)
text
CL.68
Code List
If Taken, How Often: Medicine to improve circulation (j.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Insulin injections for diabetes (j.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.69
Code List
Insulin injections for diabetes (j.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Insulin injections for diabetes (k.)
text
CL.70
Code List
If Taken, How Often: Insulin injections for diabetes (k.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Pills for diabetes (k.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.71
Code List
Pills for diabetes (k.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Pills for diabetes (l.)
text
CL.72
Code List
If Taken, How Often: Pills for diabetes (l.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Ulcer medicine (l.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.73
Code List
Ulcer medicine (l.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Ulcer medicine (m.)
text
CL.74
Code List
If Taken, How Often: Ulcer medicine (m.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Asthma medicines (m.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.75
Code List
Asthma medicines (m.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Asthma medicines (n.)
text
CL.76
Code List
If Taken, How Often: Asthma medicines (n.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Seizure medicines (like Dilantin)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.77
Code List
Seizure medicines (like Dilantin)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Seizure medicines (like Dilantin)
text
CL.78
Code List
If Taken, How Often: Seizure medicines (like Dilantin)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item Group
Unnamed13
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Item Group
Unnamed14
Item
Thyroid pills (If Taken, How Often?)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.79
Code List
Thyroid pills (If Taken, How Often?)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Thyroid pills (p.)
text
CL.80
Code List
If Taken, How Often: Thyroid pills (p.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Cortisone pills or injections (p.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.81
Code List
Cortisone pills or injections (p.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Cortisone pills or injections (q.)
text
CL.82
Code List
If Taken, How Often: Cortisone pills or injections (q.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Antibiotics (q.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.83
Code List
Antibiotics (q.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Antibiotics (r.)
text
CL.84
Code List
If Taken, How Often: Antibiotics (r.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Tranquilizers or medicine for your nerves (r.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.85
Code List
Tranquilizers or medicine for your nerves (r.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
text
CL.86
Code List
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Prescription sleeping pills (s.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.87
Code List
Prescription sleeping pills (s.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Prescription sleeping pills (t.)
text
CL.88
Code List
If Taken, How Often: Prescription sleeping pills (t.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Over-the-counter pills to help you sleep (t.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.89
Code List
Over-the-counter pills to help you sleep (t.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
text
CL.90
Code List
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Hormones (male or female)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.91
Code List
Hormones (male or female)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Hormones (v.)
text
CL.92
Code List
If Taken, How Often: Hormones (v.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Allergy medicines (v.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.93
Code List
Allergy medicines (v.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Allergy medicines (w.)
text
CL.94
Code List
If Taken, How Often: Allergy medicines (w.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Laxatives (w.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.95
Code List
Laxatives (w.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Laxatives (x.)
text
CL.96
Code List
If Taken, How Often: Laxatives (x.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Eye drops for glaucoma (x.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.97
Code List
Eye drops for glaucoma (x.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Eye drops for glaucoma (y.)
text
CL.98
Code List
If Taken, How Often: Eye drops for glaucoma (y.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Calcium tablets (y.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.99
Code List
Calcium tablets (y.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Calcium tablets (z.)
text
CL.100
Code List
If Taken, How Often: Calcium tablets (z.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Vitamins and/or minerals (other than calcium)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.101
Code List
Vitamins and/or minerals (other than calcium)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Vitamins and/or minerals (other than calcium)
text
CL.102
Code List
If Taken, How Often: Vitamins and/or minerals (other than calcium)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item
Herbal medicines (aa.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.103
Code List
Herbal medicines (aa.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Taken, How Often: Herbal medicines (12.)
text
CL.104
Code List
If Taken, How Often: Herbal medicines (12.)
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take As Needed)
Item Group
Unnamed15
Item
Have you taken any other medicines in the past month?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.105
Code List
Have you taken any other medicines in the past month?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NameofMedicine
Item
Name of Medicine
text
Item
If Taken, How Often?
text
CL.106
Code List
If Taken, How Often?
CL Item
Once A Day (Once a Day)
CL Item
More Than Once A Day (More than Once a Day)
CL Item
Take As Needed (Take as Needed))
Item Group
Ccrr Module For Calgb : 49907 Your Health (form C)
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial