ID

6220

Beschreibung

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

Stichworte

Versionen (3)
  1. 18.12.14 18.12.14 - Martin Dugas
  2. 20.03.15 20.03.15 - Martin Dugas
  3. 20.09.21 20.09.21 -
Hochgeladen am

18. Dezember 2014

DOI

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

Englisch

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 Formulare  
Unnamed1
Beschreibung

Unnamed1

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Date Completed (Medicine)
Beschreibung

DateCompleted

Datentyp

date

Amended data?
Beschreibung

Amendeddata?

Datentyp

text

Unnamed2
Beschreibung

Unnamed2

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

Participating Group
Beschreibung

ParticipatingGroup

Datentyp

text

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

PatientHospitalNumber

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Main Member Institution/Adjunct
Beschreibung

MainMemberInstitution/Adjunct

Datentyp

text

Participating Group Patient No.
Beschreibung

ParticipatingGroupPatientNo.

Datentyp

text

Unnamed3
Beschreibung

Unnamed3

Responsible CRA
Beschreibung

ResponsibleCRA

Datentyp

text

Assessment Number (1. Your General Health)
Beschreibung

AssessmentNumber

Datentyp

double

Unnamed4
Beschreibung

Unnamed4

Other cancers or leukemia (a.)
Beschreibung

Othercancersorleukemia

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:Othercancersorleukemia

Datentyp

text

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

Arthritis,rheumatism,orotherconnectivetissuedisorders

Datentyp

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.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders

Datentyp

text

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

Glaucoma

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:Glaucoma

Datentyp

text

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

EmphysemaorChronicBronchitis

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis

Datentyp

text

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

HighBloodPressure

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:HighBloodPressure

Datentyp

text

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

Heartdisease

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:Heartdisease

Datentyp

text

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

Circulationtroubleinarmsorlegs

Datentyp

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.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs

Datentyp

text

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

Diabetes

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:Diabetes

Datentyp

text

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

Stomachorintestinaldisorders

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders

Datentyp

text

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

Osteoporosis

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:Osteoporosis

Datentyp

text

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

ChronicLiverorKidneyDisease

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:ChronicLiverorKidneyDisease

Datentyp

text

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

Stroke

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:Stroke

Datentyp

text

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

Depression

Datentyp

text

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

Howmuchdoesitinterferewithyouractivities:Depression

Datentyp

text

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

Unnamed5

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Date Completed (Medicine)
Beschreibung

DateCompleted

Datentyp

date

Unnamed6
Beschreibung

Unnamed6

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

Howisyoureyesight(withglassesorcontacts)?

Datentyp

text

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

Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?

Datentyp

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)
Beschreibung

Howifyourhearing(withahearingaid,ifneeded)?

Datentyp

text

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

Iffair,poorortotallydeaf,howmuchdoesthisinterferewithyouractivities?

Datentyp

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?
Beschreibung

Doyouhaveanyotherphysicalproblemsorillnesses(thanlistedinquestion1-3)atthepresenttimethatseriouslyaffectyourhealth?

Datentyp

text

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

Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)

Datentyp

text

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

howmuchdoesthisinterferewithyouractivities?

Datentyp

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.)
Beschreibung

Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?

Datentyp

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)
Beschreibung

Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?

Datentyp

text

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

Howmanydaysinthepast3monthswereyouinahospitalforphysicalhealthproblems?

Datentyp

text

Unnamed7
Beschreibung

Unnamed7

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Date Completed (Medicine)
Beschreibung

DateCompleted

Datentyp

date

Unnamed8
Beschreibung

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.)
Beschreibung

Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?

Datentyp

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)
Beschreibung

Whattypeofcounselingortreatmentdidyoureceive?

Datentyp

text

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

Other,specify(typeofcounselingortreatmentreceived)

Datentyp

text

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

Checkanyoftheseservicesthatyouarestillreceiving

Datentyp

text

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

Other,specify(servicesthatyouarestillreceiving)

Datentyp

text

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

Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?

Datentyp

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)
Beschreibung

Whattypeofcounselingortreatmentdidyoureceive?(follow-up)

Datentyp

text

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

Other,specify(typeofcounselingortreatmentreceived;follow-up)

Datentyp

text

Unnamed9
Beschreibung

Unnamed9

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Date Completed (Medicine)
Beschreibung

DateCompleted

Datentyp

date

Unnamed10
Beschreibung

Unnamed10

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

Checkanyoftheseservicesthatyouarestillreceiving(follow-up)

Datentyp

text

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

Other,specify(servicesthatyouarestillreceiving;follow-up)

Datentyp

text

Medicine to treat nausea and/or vomiting
Beschreibung

Medicinetotreatnauseaand/orvomiting

Datentyp

text

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

Medicinetotreatdiarrhea

Datentyp

text

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

Medicinetoreducefeelingverytired[fatigue]

Datentyp

text

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

Medicinetoreduceswellinginhandsorfeet

Datentyp

text

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

Medicineorcreamtotreatmouthsores

Datentyp

text

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

Painmedicineforhandsorfeet

Datentyp

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
Beschreibung

Medicineorcreamtotreatskinchanges(e.g.redness,peeling)inhandsorfeet

Datentyp

text

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

Other,specify

Datentyp

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)
Beschreibung

Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)

Datentyp

text

Unnamed11
Beschreibung

Unnamed11

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Date Completed (Medicine)
Beschreibung

DateCompleted

Datentyp

date

Unnamed12
Beschreibung

Unnamed12

Arthritis medicine (If Taken, How Often?)
Beschreibung

Arthritismedicine

Datentyp

text

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

IfTaken,HowOften:Arthritismedicine

Datentyp

text

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

Prescriptionpainkiller

Datentyp

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)
Beschreibung

IfTaken,HowOften:Prescriptionpainkiller

Datentyp

text

Over-the counter pain killers (c.)
Beschreibung

Over-thecounterpainkillers

Datentyp

text

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

IfTaken,HowOften:Over-thecounterpainkillers

Datentyp

text

High blood pressure medicine (d.)
Beschreibung

Highbloodpressuremedicine

Datentyp

text

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

IfTaken,HowOften:Highbloodpressuremedicine

Datentyp

text

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

Pillstomakeyoulosewaterorsalt

Datentyp

text

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

IfTaken,HowOften:Pillstomakeyoulosewaterorsalt

Datentyp

text

Digoxin pills for the heart (Lanoxin)
Beschreibung

Digoxinpillsfortheheart

Datentyp

text

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

IfTaken,HowOften:Digoxinpillsfortheheart

Datentyp

text

Nitroglycerin for chest pain (tablets or patches)
Beschreibung

Nitroglycerinforchestpain

Datentyp

text

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

IfTaken,HowOften:Nitroglycerinforchestpain

Datentyp

text

Blood thinner medicine (anticoagulants)
Beschreibung

Bloodthinnermedicine

Datentyp

text

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

IfTaken,HowOften:Bloodthinnermedicine

Datentyp

text

Medicine to improve circulation (i.)
Beschreibung

Medicinetoimprovecirculation

Datentyp

text

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

IfTaken,HowOften:Medicinetoimprovecirculation

Datentyp

text

Insulin injections for diabetes (j.)
Beschreibung

Insulininjectionsfordiabetes

Datentyp

text

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

IfTaken,HowOften:Insulininjectionsfordiabetes

Datentyp

text

Pills for diabetes (k.)
Beschreibung

Pillsfordiabetes

Datentyp

text

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

IfTaken,HowOften:Pillsfordiabetes

Datentyp

text

Ulcer medicine (l.)
Beschreibung

Ulcermedicine

Datentyp

text

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

IfTaken,HowOften:Ulcermedicine

Datentyp

text

Asthma medicines (m.)
Beschreibung

Asthmamedicines

Datentyp

text

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

IfTaken,HowOften:Asthmamedicines

Datentyp

text

Seizure medicines (like Dilantin)
Beschreibung

Seizuremedicines

Datentyp

text

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

IfTaken,HowOften:Seizuremedicines

Datentyp

text

Unnamed13
Beschreibung

Unnamed13

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Date Completed (Medicine)
Beschreibung

DateCompleted

Datentyp

date

Unnamed14
Beschreibung

Unnamed14

Thyroid pills (If Taken, How Often?)
Beschreibung

Thyroidpills

Datentyp

text

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

IfTaken,HowOften:Thyroidpills

Datentyp

text

Cortisone pills or injections (p.)
Beschreibung

Cortisonepillsorinjections

Datentyp

text

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

IfTaken,HowOften:Cortisonepillsorinjections

Datentyp

text

Antibiotics (q.)
Beschreibung

Antibiotics

Datentyp

text

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

IfTaken,HowOften:Antibiotics

Datentyp

text

Tranquilizers or medicine for your nerves (r.)
Beschreibung

Tranquilizersormedicineforyournerves

Datentyp

text

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

IfTaken,HowOften:Tranquilizersormedicineforyournerves

Datentyp

text

Prescription sleeping pills (s.)
Beschreibung

Prescriptionsleepingpills

Datentyp

text

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

IfTaken,HowOften:Prescriptionsleepingpills

Datentyp

text

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

Over-the-counterpillstohelpyousleep

Datentyp

text

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

IfTaken,HowOften:Over-the-counterpillstohelpyousleep

Datentyp

text

Hormones (male or female)
Beschreibung

Hormones

Datentyp

text

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

IfTaken,HowOften:Hormones

Datentyp

text

Allergy medicines (v.)
Beschreibung

Allergymedicines

Datentyp

text

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

IfTaken,HowOften:Allergymedicines

Datentyp

text

Laxatives (w.)
Beschreibung

Laxatives

Datentyp

text

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

IfTaken,HowOften:Laxatives

Datentyp

text

Eye drops for glaucoma (x.)
Beschreibung

Eyedropsforglaucoma

Datentyp

text

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

IfTaken,HowOften:Eyedropsforglaucoma

Datentyp

text

Calcium tablets (y.)
Beschreibung

Calciumtablets

Datentyp

text

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

IfTaken,HowOften:Calciumtablets

Datentyp

text

Vitamins and/or minerals (other than calcium)
Beschreibung

Vitaminsand/orminerals

Datentyp

text

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

IfTaken,HowOften:Vitaminsand/orminerals

Datentyp

text

Herbal medicines (aa.)
Beschreibung

Herbalmedicines

Datentyp

text

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

IfTaken,HowOften:Herbalmedicines

Datentyp

text

Unnamed15
Beschreibung

Unnamed15

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

Haveyoutakenanyothermedicinesinthepastmonth?

Datentyp

text

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

NameofMedicine

Datentyp

text

If Taken, How Often?
Beschreibung

IfTaken,HowOften?

Datentyp

text

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

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

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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 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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)
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