ID

6220

Descrição

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

Palavras-chave

Versões (3)
  1. 18/12/2014 18/12/2014 - Martin Dugas
  2. 20/03/2015 20/03/2015 - Martin Dugas
  3. 20/09/2021 20/09/2021 -
Transferido a

18 de dezembro de 2014

DOI

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Licença

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

Inglês

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 Formulários  
Unnamed1
Descrição

Unnamed1

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBStudyNo

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Date Completed (Medicine)
Descrição

DateCompleted

Tipo de dados

date

Amended data?
Descrição

Amendeddata?

Tipo de dados

text

Unnamed2
Descrição

Unnamed2

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

Participating Group
Descrição

ParticipatingGroup

Tipo de dados

text

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

PatientHospitalNumber

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Main Member Institution/Adjunct
Descrição

MainMemberInstitution/Adjunct

Tipo de dados

text

Participating Group Patient No.
Descrição

ParticipatingGroupPatientNo.

Tipo de dados

text

Unnamed3
Descrição

Unnamed3

Responsible CRA
Descrição

ResponsibleCRA

Tipo de dados

text

Assessment Number (1. Your General Health)
Descrição

AssessmentNumber

Tipo de dados

double

Unnamed4
Descrição

Unnamed4

Other cancers or leukemia (a.)
Descrição

Othercancersorleukemia

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:Othercancersorleukemia

Tipo de dados

text

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

Arthritis,rheumatism,orotherconnectivetissuedisorders

Tipo de dados

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.)
Descrição

Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders

Tipo de dados

text

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

Glaucoma

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:Glaucoma

Tipo de dados

text

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

EmphysemaorChronicBronchitis

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis

Tipo de dados

text

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

HighBloodPressure

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:HighBloodPressure

Tipo de dados

text

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

Heartdisease

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:Heartdisease

Tipo de dados

text

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

Circulationtroubleinarmsorlegs

Tipo de dados

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.)
Descrição

Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs

Tipo de dados

text

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

Diabetes

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:Diabetes

Tipo de dados

text

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

Stomachorintestinaldisorders

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders

Tipo de dados

text

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

Osteoporosis

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:Osteoporosis

Tipo de dados

text

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

ChronicLiverorKidneyDisease

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:ChronicLiverorKidneyDisease

Tipo de dados

text

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

Stroke

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:Stroke

Tipo de dados

text

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

Depression

Tipo de dados

text

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

Howmuchdoesitinterferewithyouractivities:Depression

Tipo de dados

text

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

Unnamed5

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBStudyNo

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Date Completed (Medicine)
Descrição

DateCompleted

Tipo de dados

date

Unnamed6
Descrição

Unnamed6

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

Howisyoureyesight(withglassesorcontacts)?

Tipo de dados

text

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

Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?

Tipo de dados

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)
Descrição

Howifyourhearing(withahearingaid,ifneeded)?

Tipo de dados

text

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

Iffair,poorortotallydeaf,howmuchdoesthisinterferewithyouractivities?

Tipo de dados

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?
Descrição

Doyouhaveanyotherphysicalproblemsorillnesses(thanlistedinquestion1-3)atthepresenttimethatseriouslyaffectyourhealth?

Tipo de dados

text

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

Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)

Tipo de dados

text

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

howmuchdoesthisinterferewithyouractivities?

Tipo de dados

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.)
Descrição

Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?

Tipo de dados

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)
Descrição

Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?

Tipo de dados

text

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

Howmanydaysinthepast3monthswereyouinahospitalforphysicalhealthproblems?

Tipo de dados

text

Unnamed7
Descrição

Unnamed7

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBStudyNo

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Date Completed (Medicine)
Descrição

DateCompleted

Tipo de dados

date

Unnamed8
Descrição

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.)
Descrição

Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?

Tipo de dados

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)
Descrição

Whattypeofcounselingortreatmentdidyoureceive?

Tipo de dados

text

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

Other,specify(typeofcounselingortreatmentreceived)

Tipo de dados

text

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

Checkanyoftheseservicesthatyouarestillreceiving

Tipo de dados

text

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

Other,specify(servicesthatyouarestillreceiving)

Tipo de dados

text

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

Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?

Tipo de dados

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)
Descrição

Whattypeofcounselingortreatmentdidyoureceive?(follow-up)

Tipo de dados

text

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

Other,specify(typeofcounselingortreatmentreceived;follow-up)

Tipo de dados

text

Unnamed9
Descrição

Unnamed9

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBStudyNo

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Date Completed (Medicine)
Descrição

DateCompleted

Tipo de dados

date

Unnamed10
Descrição

Unnamed10

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

Checkanyoftheseservicesthatyouarestillreceiving(follow-up)

Tipo de dados

text

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

Other,specify(servicesthatyouarestillreceiving;follow-up)

Tipo de dados

text

Medicine to treat nausea and/or vomiting
Descrição

Medicinetotreatnauseaand/orvomiting

Tipo de dados

text

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

Medicinetotreatdiarrhea

Tipo de dados

text

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

Medicinetoreducefeelingverytired[fatigue]

Tipo de dados

text

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

Medicinetoreduceswellinginhandsorfeet

Tipo de dados

text

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

Medicineorcreamtotreatmouthsores

Tipo de dados

text

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

Painmedicineforhandsorfeet

Tipo de dados

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
Descrição

Medicineorcreamtotreatskinchanges(e.g.redness,peeling)inhandsorfeet

Tipo de dados

text

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

Other,specify

Tipo de dados

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)
Descrição

Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)

Tipo de dados

text

Unnamed11
Descrição

Unnamed11

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBStudyNo

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Date Completed (Medicine)
Descrição

DateCompleted

Tipo de dados

date

Unnamed12
Descrição

Unnamed12

Arthritis medicine (If Taken, How Often?)
Descrição

Arthritismedicine

Tipo de dados

text

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

IfTaken,HowOften:Arthritismedicine

Tipo de dados

text

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

Prescriptionpainkiller

Tipo de dados

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)
Descrição

IfTaken,HowOften:Prescriptionpainkiller

Tipo de dados

text

Over-the counter pain killers (c.)
Descrição

Over-thecounterpainkillers

Tipo de dados

text

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

IfTaken,HowOften:Over-thecounterpainkillers

Tipo de dados

text

High blood pressure medicine (d.)
Descrição

Highbloodpressuremedicine

Tipo de dados

text

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

IfTaken,HowOften:Highbloodpressuremedicine

Tipo de dados

text

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

Pillstomakeyoulosewaterorsalt

Tipo de dados

text

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

IfTaken,HowOften:Pillstomakeyoulosewaterorsalt

Tipo de dados

text

Digoxin pills for the heart (Lanoxin)
Descrição

Digoxinpillsfortheheart

Tipo de dados

text

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

IfTaken,HowOften:Digoxinpillsfortheheart

Tipo de dados

text

Nitroglycerin for chest pain (tablets or patches)
Descrição

Nitroglycerinforchestpain

Tipo de dados

text

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

IfTaken,HowOften:Nitroglycerinforchestpain

Tipo de dados

text

Blood thinner medicine (anticoagulants)
Descrição

Bloodthinnermedicine

Tipo de dados

text

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

IfTaken,HowOften:Bloodthinnermedicine

Tipo de dados

text

Medicine to improve circulation (i.)
Descrição

Medicinetoimprovecirculation

Tipo de dados

text

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

IfTaken,HowOften:Medicinetoimprovecirculation

Tipo de dados

text

Insulin injections for diabetes (j.)
Descrição

Insulininjectionsfordiabetes

Tipo de dados

text

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

IfTaken,HowOften:Insulininjectionsfordiabetes

Tipo de dados

text

Pills for diabetes (k.)
Descrição

Pillsfordiabetes

Tipo de dados

text

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

IfTaken,HowOften:Pillsfordiabetes

Tipo de dados

text

Ulcer medicine (l.)
Descrição

Ulcermedicine

Tipo de dados

text

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

IfTaken,HowOften:Ulcermedicine

Tipo de dados

text

Asthma medicines (m.)
Descrição

Asthmamedicines

Tipo de dados

text

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

IfTaken,HowOften:Asthmamedicines

Tipo de dados

text

Seizure medicines (like Dilantin)
Descrição

Seizuremedicines

Tipo de dados

text

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

IfTaken,HowOften:Seizuremedicines

Tipo de dados

text

Unnamed13
Descrição

Unnamed13

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBStudyNo

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Date Completed (Medicine)
Descrição

DateCompleted

Tipo de dados

date

Unnamed14
Descrição

Unnamed14

Thyroid pills (If Taken, How Often?)
Descrição

Thyroidpills

Tipo de dados

text

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

IfTaken,HowOften:Thyroidpills

Tipo de dados

text

Cortisone pills or injections (p.)
Descrição

Cortisonepillsorinjections

Tipo de dados

text

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

IfTaken,HowOften:Cortisonepillsorinjections

Tipo de dados

text

Antibiotics (q.)
Descrição

Antibiotics

Tipo de dados

text

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

IfTaken,HowOften:Antibiotics

Tipo de dados

text

Tranquilizers or medicine for your nerves (r.)
Descrição

Tranquilizersormedicineforyournerves

Tipo de dados

text

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

IfTaken,HowOften:Tranquilizersormedicineforyournerves

Tipo de dados

text

Prescription sleeping pills (s.)
Descrição

Prescriptionsleepingpills

Tipo de dados

text

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

IfTaken,HowOften:Prescriptionsleepingpills

Tipo de dados

text

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

Over-the-counterpillstohelpyousleep

Tipo de dados

text

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

IfTaken,HowOften:Over-the-counterpillstohelpyousleep

Tipo de dados

text

Hormones (male or female)
Descrição

Hormones

Tipo de dados

text

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

IfTaken,HowOften:Hormones

Tipo de dados

text

Allergy medicines (v.)
Descrição

Allergymedicines

Tipo de dados

text

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

IfTaken,HowOften:Allergymedicines

Tipo de dados

text

Laxatives (w.)
Descrição

Laxatives

Tipo de dados

text

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

IfTaken,HowOften:Laxatives

Tipo de dados

text

Eye drops for glaucoma (x.)
Descrição

Eyedropsforglaucoma

Tipo de dados

text

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

IfTaken,HowOften:Eyedropsforglaucoma

Tipo de dados

text

Calcium tablets (y.)
Descrição

Calciumtablets

Tipo de dados

text

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

IfTaken,HowOften:Calciumtablets

Tipo de dados

text

Vitamins and/or minerals (other than calcium)
Descrição

Vitaminsand/orminerals

Tipo de dados

text

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

IfTaken,HowOften:Vitaminsand/orminerals

Tipo de dados

text

Herbal medicines (aa.)
Descrição

Herbalmedicines

Tipo de dados

text

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

IfTaken,HowOften:Herbalmedicines

Tipo de dados

text

Unnamed15
Descrição

Unnamed15

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

Haveyoutakenanyothermedicinesinthepastmonth?

Tipo de dados

text

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

NameofMedicine

Tipo de dados

text

If Taken, How Often?
Descrição

IfTaken,HowOften?

Tipo de dados

text

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

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 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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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