ID

866

Beskrivning

NSABP PROTOCOL B-36 Follow-Up Menstrual History Questionnaire Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C891F490-0A7E-745C-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C891F490-0A7E-745C-E034-0003BA12F5E7

Nyckelord

Versioner (3)
  1. 2012-08-26 2012-08-26 -
  2. 2015-05-22 2015-05-22 -
  3. 2015-06-03 2015-06-03 -
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26 augusti 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00087178 Follow-Up - NSABP PROTOCOL B-36 Follow-Up Menstrual History Questionnaire - 2175213v3.0

Engelsk

(For participants in the follow-up phase of the Menstrual History Study)

1 Formulär  
  1. StudyEvent: NSABP PROTOCOL B-36 Follow-Up Menstrual History Questionnaire
    1. (For participants in the follow-up phase of the Menstrual History Study)
Unnamed1
Beskrivning

Unnamed1

Institution Name
Beskrivning

InstitutionName

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Affiliated Institution Name
Beskrivning

AffiliatedInstitutionName

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ObjectClass
C25413
UMLS 2011AA ObjectClass
C1510826
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
Person Form Administration Last Name
Beskrivning

PersonFormAdministrationLastName

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C25551
UMLS 2011AA ValueDomain
C1517741
Person Form Administration First Name
Beskrivning

PersonFormAdministrationFirstName

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C25509
UMLS 2011AA ValueDomain
C1279901
Staff Member Administering Form, Phone
Beskrivning

PersonFormAdministrationPhoneNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
Data Amended Ind-3
Beskrivning

DataAmendedInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed2
Beskrivning

Unnamed2

Time Point for this Questionnaire (Evaluations should be carried out according to schedule, even if the patient discontinues protocol therapy. Patients who have experienced breast cancer recurrence or second primary cancer do not need to fill out this form.)
Beskrivning

TimePointforthisQuestionnaire

Datatyp

text

Date Questionnaire Completed (Month Day Year)
Beskrivning

QualityofLifeCompleteAssessmentDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25367
Unnamed3
Beskrivning

Unnamed3

NSABP Patient ID
Beskrivning

PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C15818
UMLS 2011AA Property
C1513905
Unnamed4
Beskrivning

Unnamed4

Have you had your uterus removed?
Beskrivning

UterusRemovedInd-3

Datatyp

text

Have you had both your ovaries removed?
Beskrivning

OvaryRemovedInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C12404
UMLS 2011AA ObjectClass
C0029939
NCI Thesaurus Property
C25650
UMLS 2011AA Property
C0849355
Have you had a menstrual period or vaginal bleeding in the last 12 months?
Beskrivning

MensesOccurrenceInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ObjectClass
C3232
UMLS 2011AA ObjectClass
C0025344
did you period stop or become less frequent during the last 12 months? (If yes,)
Beskrivning

MensesEndOccurrenceInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ObjectClass
C3232
UMLS 2011AA ObjectClass
C0025344
NCI Thesaurus Property
C25496
UMLS 2011AA Property
C2746065
When was your last menstrual period (or vaginal bleeding)? (Month Year)
Beskrivning

Firstdayoflastmenstrualperiod

Datatyp

text

Ccrr Module For Nsabp Protocol B-36 Follow-up Menstrual History Questionnaire
Beskrivning

Ccrr Module For Nsabp Protocol B-36 Follow-up Menstrual History Questionnaire

Tillbaka till toppen

Similar models

(For participants in the follow-up phase of the Menstrual History Study)

1 Formulär
  1. StudyEvent: NSABP PROTOCOL B-36 Follow-Up Menstrual History Questionnaire
    1. (For participants in the follow-up phase of the Menstrual History Study)
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Unnamed1
InstitutionName
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
AffiliatedInstitutionName
Item
Affiliated Institution Name
text
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25413 (NCI Thesaurus ObjectClass)
C1510826 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
PersonFormAdministrationLastName
Item
Person Form Administration Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain)
C1517741 (UMLS 2011AA ValueDomain)
PersonFormAdministrationFirstName
Item
Person Form Administration First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25509 (NCI Thesaurus ValueDomain)
C1279901 (UMLS 2011AA ValueDomain)
PersonFormAdministrationPhoneNumber
Item
Staff Member Administering Form, Phone
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
Item
Data Amended Ind-3
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Data Amended Ind-3
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
Item
Time Point for this Questionnaire (Evaluations should be carried out according to schedule, even if the patient discontinues protocol therapy. Patients who have experienced breast cancer recurrence or second primary cancer do not need to fill out this form.)
text
CL.2
Code List
Time Point for this Questionnaire (Evaluations should be carried out according to schedule, even if the patient discontinues protocol therapy. Patients who have experienced breast cancer recurrence or second primary cancer do not need to fill out this form.)
CL Item
Day 1 of Cycle #4 (Day 1 of Cycle #4)
CL Item
6-Month Follow-up (6-Month Follow-up)
CL Item
12-Month Follow-up (12-Month Follow-up)
CL Item
18-Month Follow-up (18-Month Follow-up)
CL Item
24-Month Follow-up (24-Month Follow-up)
CL Item
30-Month Follow-up (30-Month Follow-up)
CL Item
36-Month Follow-up (36-Month Follow-up)
CL Item
42-Month Follow-up (42-Month Follow-up)
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed (Month Day Year)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
Item Group
Unnamed3
PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C15818 (NCI Thesaurus Property)
C1513905 (UMLS 2011AA Property)
Item Group
Unnamed4
Item
Have you had your uterus removed?
text
CL.3
Code List
Have you had your uterus removed?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unsure (Unsure)
Item
Have you had both your ovaries removed?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12404 (NCI Thesaurus ObjectClass)
C0029939 (UMLS 2011AA ObjectClass)
C25650 (NCI Thesaurus Property)
C0849355 (UMLS 2011AA Property)
CL.4
Code List
Have you had both your ovaries removed?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unsure (Unsure)
Item
Have you had a menstrual period or vaginal bleeding in the last 12 months?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C3232 (NCI Thesaurus ObjectClass)
C0025344 (UMLS 2011AA ObjectClass)
CL.5
Code List
Have you had a menstrual period or vaginal bleeding in the last 12 months?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unsure (Unsure)
Item
did you period stop or become less frequent during the last 12 months? (If yes,)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C3232 (NCI Thesaurus ObjectClass)
C0025344 (UMLS 2011AA ObjectClass)
C25496 (NCI Thesaurus Property)
C2746065 (UMLS 2011AA Property)
CL.6
Code List
did you period stop or become less frequent during the last 12 months? (If yes,)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unsure (Unsure)
Firstdayoflastmenstrualperiod
Item
When was your last menstrual period (or vaginal bleeding)? (Month Year)
text
Item Group
Ccrr Module For Nsabp Protocol B-36 Follow-up Menstrual History Questionnaire
Tillbaka till toppen 

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