| CDE ID | CDE Description | | * 421 | EDRN Participant ID (Go To: 2176) |
| * 2176 | Visit code (Go To: 422) |
| | | Permissible Values (value): | BLN1 (1) |
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| * 423 | EDRN Protocol ID (Go To: 422) |
| * 422 | EDRN Site ID (Go To: 929) |
| * 929 | EDRN Staff ID of the person who collected the data: (Go To: 1219) |
| * 1219 | Date of contact (MM/DD/YYYY): (Go To: 2973) |
| * 2973 | History of Inflammatory Bowel Disease, such as Crohn’s Disease or colitis? (Go To: 2961) |
| | | Permissible Values (value): | No (0) |
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| | | | Yes (1) (Go To: End of Form) |
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| * 2961 | Have you seen blood in your bowel movements, blood in the toilet bowl, or blood on the toilet tissue? (Go To: 2978) |
| | | Permissible Values (value): | No (0) |
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| * 2978 | Has a doctor told you that you have occult (hidden) blood in your stool, based on FOBT (Fecal Occult Blood Test) cards? (Go To: 2969) |
| | | Permissible Values (value): | No (0) |
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| * 2969 | Have you had surgery for the removal of all or part of the following? (Check all that apply) (Go To: 2972) |
| | | Permissible Values (value): | Appendix (1) |
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| * 2972 | Diagnosed with HIV? (Go To: 2968) |
| | | Permissible Values (value): | No (0) |
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| | | | Yes (1) (Go To: End of Form) |
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| * 2968 | Has a doctor ever diagnosed you with Familial Adenomatous Polyposis (FAP) (Gardner’s Syndrome), or Hereditary Non-Polyposis Colon Syndrome (HNPCC), also called Lynch Syndrome? (Go To: 2977) |
| | | Permissible Values (value): | No (0) |
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| | | | Yes (1) (Go To: End of Form) |
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| * 2977 | Has a doctor diagnosed you with any of the following inflammations? (Check all that apply) (Go To: 3172) |
| | | Permissible Values (value): | Rheumatoid arthritis (1) |
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| | | | Inflammatory bowel disease (3) |
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| | | | Collagen vascular disease such as lupus or scleroderma (8) |
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| | | | Other, specify: (97) (Go To: 3006) |
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| * 3006 | Inflammation name (Other, specify): (Go To: 3172) |
| * 3172 | History of sigmoidoscopy? (Go To: 2964) |
| | | Permissible Values (value): | No (0) |
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| * 2964 | How many colonoscopies have you had? Do not include any colonoscopies that are scheduled, but have not yet taken place. (Colonoscopy is an exam of the entire large bowel using a long flexible instrument. The exam is usually done under sedation.) (Go To: 2783) |
| | | Permissible Values (value): | None (0) |
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| | | | 1 colonoscopy (1) (Go To: 2997) |
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| | | | 2 colonoscopies (2) (Go To: 2997) |
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| | | | 3 or more colonoscopies (3) (Go To: 2997) |
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| * 2997 | Number of months since last colonoscopy: (Go To: 3148) |
| 3148 | Full colonoscopy? (Go To: 2783) |
| | | Permissible Values (value): | No (0) |
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| * 2783 | Ever diagnosed with polyps? (Go To: 1307) |
| | | Permissible Values (value): | No (0) |
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| * 2974 | Number of colon polyps: (Go To: 2987) |
| | | Permissible Values (value): | 1-2 (1) |
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| * 2987 | Were adenomas found? (Go To: 2963) |
| | | Permissible Values (value): | No (0) |
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| * 2963 | Was any polyp or growth diagnosed as cancerous (malignant)? (Go To: 1307) |
| | | Permissible Values (value): | No (0) |
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| * 1307 | Ever had cancer [other than basal/squamous cell skin cancer] confirmed by a doctor? (Have you ever had cancer [other than basal/squamous cell skin cancer] confirmed by a doctor?) (Go To: 4950) |
| | | Permissible Values (value): | No (0) |
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| * 3142 | Number of cancers to record: (Go To: 2159) |
| | | Permissible Values (value): | 1 (1) |
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| * 2159 | Specimen line number or identifier (system-generated): (Go To: 1341) |
| * 1341 | Cancer type/location (Go To: 2148) |
| | | Permissible Values (value): | Bladder (1) |
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| | | | Endometrium (22) (Go To: 2992) |
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| | | | Head & neck (mouth, nose, and throat) (8) |
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| | | | Lymphoma, including Hodgkins (13) |
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| | | | Skin (melanoma, no basal or squamous) (18) |
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| | | | Unknown (99) (Go To: 3158) |
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| * 2991 | Cervical stage group: (Go To: 3021) |
| | | Permissible Values (value): | Stage 0 (1) |
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| * 3021 | Cancer treatments received (third instance): (Go To: 1333) |
| | | Permissible Values (value): | Chemotherapy (1) |
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| * 2992 | Histopathologic stage group (endometrium): (Go To: 2956) |
| | | Permissible Values (value): | Stage 0 (1) |
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| * 2956 | Cancer treatment received (second instance): (Go To: 1333) |
| | | Permissible Values (value): | Chemotherapy (1) |
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| * 2148 | Primary cancer treatment(s) received: (Go To: 1333) |
| | | Permissible Values (value): | Chemotherapy (1) (Go To: 1260) |
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| | | | Radiation therapy (2) (Go To: 1263) |
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| | | | Surgery (3) (Go To: 3014) |
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| * 3014 | Date of most recent cancer-related surgery (MM/YYYY): (Go To: 1333) |
| * 1263 | Radiation therapy end date: (MM/YYYY): (Go To: 1333) |
| * 1260 | Chemotherapy end date (MM/YYYY): (Go To: 1333) |
| * 1333 | Date of diagnosis (MM/YYYY): (Go To: 1357) |
| * 1357 | Tumor laterality (Go To: 4669) |
| | | Permissible Values (value): | Right (1) |
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| * 4669 | Diagnosis code, ICD-9 (Go To: 1338) |
| * 1338 | Histologic confirmation? (Go To: 1358) |
| | | Permissible Values (value): | No (0) |
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| * 1358 | Chart Abstraction? (Go To: 3158) |
| | | Permissible Values (value): | No (0) |
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| 3158 | Loop-specific comments: (Go To: 4950) |
| * 4950 | Is the participant currently on active chemotherapy or radiation treatment for any reason? (Go To: 2967) |
| | | Permissible Values (value): | No (0) |
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| | | | Yes (1) (Go To: End of Form) |
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| * 2967 | History of diverticulitis? (Diverticulitis occurs when pouches in the wall of the colon become infected or inflamed, with symptoms of abdominal pain, nausea, vomiting, cramping, and constipation) (Go To: 2976) |
| | | Permissible Values (value): | No (0) |
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| * 3015 | Diverticulitis diagnosis date (MM/YYYY): (Go To: 2976) |
| * 2976 | History of Irritable Bowel Syndrome? (This is a disorder of the bowels leading to cramping, gassiness, bloating, and alternating diarrhea and constipation.) (Go To: 2962) |
| | | Permissible Values (value): | No (0) |
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| * 3026 | Irritiable Bowel Syndrome diagnosis date (MM/YYYY): (Go To: 2962) |
| * 2962 | History of any other type of bowel problem? (Go To: 2965) |
| | | Permissible Values (value): | No (0) |
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| * 3005 | Other bowel problem name: (Go To: 3017) |
| * 3017 | Other bowel problem diagnosis date (MM/YYYY): (Go To: 2965) |
| * 2965 | Have you had constipation to the point where you took a laxative at least twice a week? (Go To: 2966) |
| | | Permissible Values (value): | No (0) |
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| * 2966 | Have you had frequent (daily or almost daily) diarrhea (frequent, loose, or watery stools)? (Go To: 2971) |
| | | Permissible Values (value): | No (0) |
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| * 2971 | Have you been diagnosed by a doctor with hemorrhoids or anal fissure? (Go To: 2970) |
| | | Permissible Values (value): | No (0) |
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| * 2970 | History of heartburn symptoms? (burning in the chest/throat, especially after eating) (Go To: 2959) |
| | | Permissible Values (value): | No (0) |
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| * 2959 | History of anemia? (Anemia is a low count of red blood cells.) (Go To: 1623) |
| | | Permissible Values (value): | No (0) |
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| * 2958 | Type(s) of anemia (check all that apply): (Go To: 1623) |
| | | Permissible Values (value): | Iron deficiency (1) |
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| | | | Pernicious (This is an anemia associated with vitamin B12 deficiency.) (2) |
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| | | | Anemia associated with thalassemia or other traits (3) |
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| | | | Other, specify: (97) (Go To: 3004) |
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| * 3004 | Type of anemia (Other, specify): (Go To: 1623) |
| * 1623 | Do you have stomach ulcers, or peptic ulcer disease? (Go To: 2979) |
| | | Permissible Values (value): | No (0) |
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| * 2979 | History of pancreatitis? (Pancreatitis is an inflammation of the pancreas. It can be short-term or long-term) (Go To: 3156) |
| | | Permissible Values (value): | No (0) |
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| * 3156 | Ever diagnosed with diabetes by a doctor? (Go To: 2960) |
| | | Permissible Values (value): | No (0) |
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| * 2960 | History of Barrett’s Esophagus? (Barrett’s Esophagus is a condition in which there are cell changes in the swallowing tube (esophagus). It develops in some people who have heartburn, reflux disease, or esophagitis (inflammation of the esophagus) (Go To: 3164) |
| | | Permissible Values (value): | No (0) |
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| * 3164 | Has a doctor diagnosed you with cirrhosis? (Cirrhosis is a chronic liver disease in which liver cells are damaged and replaced by scar tissue.) (Go To: 3165) |
| | | Permissible Values (value): | No (0) |
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| * 3165 | Has a doctor diagnosed you with yellow jaundice? (Yellow jaundice, in which the skin/eyes turn a yellowish color, is a symptom of liver problems.) (Go To: 4951) |
| | | Permissible Values (value): | No (0) |
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| * 4951 | Has the participant ever been treated with steroids such as prednisone, dexamethasone, decadron, or hydrocortisone ? Steroids are medications used to reduce or block inflammation? (Go To: 4956) |
| | | Permissible Values (value): | No (0) |
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| * 3018 | Medication start date (MM/YYYY): (Go To: 4954) |
| * 4954 | Is the medication necessary to control disease? (Go To: 4956) |
| | | Permissible Values (value): | No (0) |
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| * 4956 | Has the participant ever taken medication that suppresses the immune system such as Methotrexate, Imuran, or 6-MP? (Go To: 4952) |
| | | Permissible Values (value): | No (0) |
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| * 4952 | Has the participant ever been treated with 5-ASA drugs such as Asacol, sulfasalazine, Pentasa, or azulfidine? (Go To: 1380) |
| | | Permissible Values (value): | No (0) |
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| 4953 | Medication start date 2 (MM/YYYY) (Go To: 4955) |
| * 4955 | Is the medication necessary to control disease 2? (Go To: 1380) |
| | | Permissible Values (value): | No (0) |
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| * 1380 | Number of living and deceased first-degree blood brothers: (How many living and deceased blood-related brothers do you have? [Not including adopted, foster, half-brothers or step-brothers] (Go To: 1381) |
| * 1381 | Number of living and deceased first-degree blood sisters: (How many living and deceased blood-related sisters do you have? [Not including adopted, foster, half-sisters or step-sisters] (Go To: 1378) |
| * 1378 | Number of living and deceased blood-related sons: (How many living and deceased blood-related sons do you have? [Not including adopted, foster, or step-sons] (Go To: 1379) |
| * 1379 | Number of living and deceased blood-related daughters: (How many living and deceased blood-related daughters do you have? [Not including adopted, foster, or step-daughters] (Go To: 2957) |
| * 2957 | Has a doctor ever diagnosed any of your first-degree blood relatives (parents, siblings, children) with Hereditary Non-Polyposis Colon Syndrome (HNPCC) or Lynch Syndrome? (Go To: 1349) |
| | | Permissible Values (value): | No (0) |
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| * 1349 | Have any of the participant´s living and deceased first degree blood relatives been diagnosed with cancer [other than basal/squamous cell skin cancer]? (Have any of your living and deceased first degree blood relatives (biological parents, siblings, children) been diagnosed with cancer [other than basal/squamous cell skin cancer]? [Not including half-siblings, step-siblings, step-parents, or step-children]. (Go To: 1097) |
| | | Permissible Values (value): | No (0) |
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| * 3143 | Number of relative´s cancers to record: (Go To: 3150) |
| | | Permissible Values (value): | 1 (1) |
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| * 3150 | Specimen line number or identifier 2 (system generated): (Go To: 1351) |
| * 1351 | Relative type (mother, brother, etc) (Go To: 1311) |
| | | Permissible Values (value): | Brother (1) |
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| * 1311 | First primary cancer: (Go To: 1430) |
| | | Permissible Values (value): | Bladder (1) |
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| | | | Head & neck (mouth, nose, and throat) (8) |
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| | | | Lymphoma, including Hodgkins (13) |
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| | | | Skin (melanoma, no basal or squamous) (18) |
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| * 1430 | Relative´s age when diagnosed (Go To: 1317) |
| * 1317 | Subsequent primary cancer(s): (Go To: 3163) |
| | | Permissible Values (value): | Bladder (1) |
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| | | | Head & neck (mouth, nose, and throat) (8) |
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| | | | Lymphoma, including Hodgkins (13) |
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| | | | Skin (melanoma, no basal or squamous) (18) |
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| 3163 | Loop-specific comments 2: (Go To: 1097) |
| 1097 | Comments (do not include any participant identifiers) (Go To: End of Form) |