ID

6220

Beschrijving

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

Trefwoorden

Quality of Life

Breast Neoplasms

18-12-14 18-12-14 - Martin Dugas
20-03-15 20-03-15 - Martin Dugas
20-09-21 20-09-21 -

Geüploaded op

18 december 2014

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy

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

model
Details

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 Formulieren

StudyEvent: CALGB : 49907 YOUR HEALTH (FORM C)
1. 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.

Name

Type

Description | Question | Decode (Coded Value)

Datatype

Alias

Unnamed1

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

Amendeddata?

Item

Amended data?

text

CL.1

Code List

Amended data?

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

Unnamed2

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

Unnamed3

Item Group

Unnamed3

ResponsibleCRA

Item

Responsible CRA

text

AssessmentNumber

Item

Assessment Number (1. Your General Health)

double

Unnamed4

Item Group

Unnamed4

Othercancersorleukemia

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)

Howmuchdoesitinterferewithyouractivities:Othercancersorleukemia

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)

Arthritis,rheumatism,orotherconnectivetissuedisorders

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)

Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders

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)

Glaucoma

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)

Howmuchdoesitinterferewithyouractivities:Glaucoma

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)

EmphysemaorChronicBronchitis

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)

Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis

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)

HighBloodPressure

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)

Howmuchdoesitinterferewithyouractivities:HighBloodPressure

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)

Heartdisease

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)

Howmuchdoesitinterferewithyouractivities:Heartdisease

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)

Circulationtroubleinarmsorlegs

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)

Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs

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)

Diabetes

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)

Howmuchdoesitinterferewithyouractivities:Diabetes

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)

Stomachorintestinaldisorders

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)

Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders

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)

Osteoporosis

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)

Howmuchdoesitinterferewithyouractivities:Osteoporosis

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)

ChronicLiverorKidneyDisease

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)

Howmuchdoesitinterferewithyouractivities:ChronicLiverorKidneyDisease

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)

Stroke

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)

Howmuchdoesitinterferewithyouractivities:Stroke

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)

Depression

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)

Howmuchdoesitinterferewithyouractivities:Depression

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)

Unnamed5

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

Unnamed6

Item Group

Unnamed6

Howisyoureyesight(withglassesorcontacts)?

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)

Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?

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)

Howifyourhearing(withahearingaid,ifneeded)?

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)

Iffair,poorortotallydeaf,howmuchdoesthisinterferewithyouractivities?

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)

Doyouhaveanyotherphysicalproblemsorillnesses(thanlistedinquestion1-3)atthepresenttimethatseriouslyaffectyourhealth?

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

howmuchdoesthisinterferewithyouractivities?

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)

Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?

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)

Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?

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)

Howmanydaysinthepast3monthswereyouinahospitalforphysicalhealthproblems?

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)

Unnamed7

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

Unnamed8

Item Group

Unnamed8

Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?

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)

Whattypeofcounselingortreatmentdidyoureceive?

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

Checkanyoftheseservicesthatyouarestillreceiving

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

Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?

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)

Whattypeofcounselingortreatmentdidyoureceive?(follow-up)

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

Unnamed9

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

Unnamed10

Item Group

Unnamed10

Checkanyoftheseservicesthatyouarestillreceiving(follow-up)

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

Medicinetotreatnauseaand/orvomiting

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)

Medicinetotreatdiarrhea

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)

Medicinetoreducefeelingverytired[fatigue]

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)

Medicinetoreduceswellinginhandsorfeet

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)

Medicineorcreamtotreatmouthsores

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)

Painmedicineforhandsorfeet

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)

Medicineorcreamtotreatskinchanges(e.g.redness,peeling)inhandsorfeet

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)

Other,specify

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

Unnamed11

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

Unnamed12

Item Group

Unnamed12

Arthritismedicine

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)

IfTaken,HowOften:Arthritismedicine

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)

Prescriptionpainkiller

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)

IfTaken,HowOften:Prescriptionpainkiller

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)

Over-thecounterpainkillers

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)

IfTaken,HowOften:Over-thecounterpainkillers

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)

Highbloodpressuremedicine

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)

IfTaken,HowOften:Highbloodpressuremedicine

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)

Pillstomakeyoulosewaterorsalt

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)

IfTaken,HowOften:Pillstomakeyoulosewaterorsalt

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)

Digoxinpillsfortheheart

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)

IfTaken,HowOften:Digoxinpillsfortheheart

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)

Nitroglycerinforchestpain

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)

IfTaken,HowOften:Nitroglycerinforchestpain

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)

Bloodthinnermedicine

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)

IfTaken,HowOften:Bloodthinnermedicine

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)

Medicinetoimprovecirculation

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)

IfTaken,HowOften:Medicinetoimprovecirculation

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)

Insulininjectionsfordiabetes

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)

IfTaken,HowOften:Insulininjectionsfordiabetes

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)

Pillsfordiabetes

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)

IfTaken,HowOften:Pillsfordiabetes

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)

Ulcermedicine

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)

IfTaken,HowOften:Ulcermedicine

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)

Asthmamedicines

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)

IfTaken,HowOften:Asthmamedicines

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)

Seizuremedicines

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)

IfTaken,HowOften:Seizuremedicines

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)

Unnamed13

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

Unnamed14

Item Group

Unnamed14

Thyroidpills

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)

IfTaken,HowOften:Thyroidpills

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)

Cortisonepillsorinjections

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)

IfTaken,HowOften:Cortisonepillsorinjections

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)

Antibiotics

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)

IfTaken,HowOften:Antibiotics

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)

Tranquilizersormedicineforyournerves

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)

IfTaken,HowOften:Tranquilizersormedicineforyournerves

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)

Prescriptionsleepingpills

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)

IfTaken,HowOften:Prescriptionsleepingpills

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)

Over-the-counterpillstohelpyousleep

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)

IfTaken,HowOften:Over-the-counterpillstohelpyousleep

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)

Hormones

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)

IfTaken,HowOften:Hormones

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)

Allergymedicines

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)

IfTaken,HowOften:Allergymedicines

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)

Laxatives

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)

IfTaken,HowOften:Laxatives

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)

Eyedropsforglaucoma

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)

IfTaken,HowOften:Eyedropsforglaucoma

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)

Calciumtablets

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)

IfTaken,HowOften:Calciumtablets

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)

Vitaminsand/orminerals

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)

IfTaken,HowOften:Vitaminsand/orminerals

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)

Herbalmedicines

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)

IfTaken,HowOften:Herbalmedicines

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)

Unnamed15

Item Group

Unnamed15

Haveyoutakenanyothermedicinesinthepastmonth?

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

IfTaken,HowOften?

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))

CCRR MODULE

Item Group

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

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

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