| CDE ID | CDE Description | | * 421 | EDRN Participant ID (Go To: 1219) |
| * 1219 | Date of contact (MM/DD/YYYY): (Go To: 2176) |
| 1832 | Participant initials: (Go To: 2176) |
| * 2176 | Visit code (Go To: 423) |
| | | Permissible Values (value): | 36 months (36) |
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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: 3685) |
| * 3685 | Source of information collection (Go To: 4820) |
| | | Permissible Values (value): | Electronic medical record (4) |
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| | | | Telephone communication (6) |
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| * 4820 | Has the participant been diagnosed with study-related disease? (Go To: 1334) |
| | | Permissible Values (value): | No (0) |
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| * 4821 | Pancreatic diagnosis (check all that apply) (Go To: 1334) |
| | | Permissible Values (value): | Pancreatic cancer (1) (Go To: 4825) |
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| * 4825 | Hospital and/or clinic where diagnosis was made (Go To: 1334) |
| | | Permissible Values (value): | This hospital/clinic (1) |
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| | | | Outside hospital/clinic, specify (97) (Go To: 4826) |
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| * 4826 | Hospital and/or clinic where diagnosis was made, other, specify (Go To: 1334) |
| * 1334 | New primary cancer [other than basal/squamous cell skin cancer] confirmed by a doctor since last routine study contact? (Have you been diagnosed with a new primary cancer [other than basal/squamous cell skin cancer] since your last routine study contact?) (Go To: 2275) |
| | | Permissible Values (value): | No (0) |
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| * 1343 | Cancer type/location (Go To: 2275) |
| | | 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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| * 2275 | Chemotherapy used? (Go To: 2477) |
| | | Permissible Values (value): | No (0) |
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| * 2477 | Radiation therapy used? (Go To: 3165) |
| | | Permissible Values (value): | No (0) |
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| * 4792 | Condition(s) that were treated (Check all that apply) (Go To: 4793) |
| | | Permissible Values (value): | Acne (1) |
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| * 4793 | Body area(s) that were treated (check all that apply) (Go To: 3165) |
| | | Permissible Values (value): | Head (1) |
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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: 4795) |
| | | Permissible Values (value): | No (0) |
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| * 4795 | Has the participant experienced any of the following symptoms? (Check all that apply) (Go To: 5027) |
| | | Permissible Values (value): | None (0) |
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| | | | Back pain (3) (Go To: 5026) |
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| | | | Abdominal pain (4) (Go To: 5025) |
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| * 5026 | Severity of back pain (Go To: 5027) |
| | | Permissible Values (value): | No pain (0) |
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| | | | Mild pain (does not require narcotics) (1) |
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| | | | Severe pain (requires narcotics) (2) |
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| * 5025 | Severity of abdominal pain (Go To: 5027) |
| | | Permissible Values (value): | No pain (0) |
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| | | | Mild pain (does not require narcotics) (1) |
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| | | | Severe pain (requires narcotics) (2) |
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| * 5027 | My appetite is (Go To: 5028) |
| | | Permissible Values (value): | Very poor (1) |
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| * 5028 | When I eat (Go To: 5029) |
| | | Permissible Values (value): | I feel full after eating only a few mouthfuls (1) |
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| | | | I feel full after eating about a third of a meal (2) |
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| | | | I feel full after eating over half a meal (3) |
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| | | | I feel full after eating most of the meal (4) |
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| | | | I hardly ever feel full (5) |
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| * 5029 | Food tastes (Go To: 5030) |
| | | Permissible Values (value): | Very bad (1) |
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| * 5030 | Normally I eat (Go To: 4799) |
| | | Permissible Values (value): | Less than one meal a day (1) |
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| | | | More than three meals a day (5) |
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| * 4799 | Rate the level of your lack of appetite (Go To: 4801) |
| | | Permissible Values (value): | I dont have a lack of appetite (1) |
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| | | | Very mild (can usually be ignored) (2) (Go To: 4800) |
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| | | | Mild (can be ignored if I don’t think about it) (3) (Go To: 4800) |
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| | | | Moderate (cannot be ignored, but does not affect your lifestyle) (4) (Go To: 4800) |
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| | | | Severe (affects your life) (5) (Go To: 4800) |
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| | | | Very severe (markedly affects your life) (6) (Go To: 4800) |
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| * 4800 | Have you experienced a lack of appetite? (Go To: 4801) |
| | | Permissible Values (value): | No (0) |
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| * 4801 | How would you compare your appetite (desire to eat) now to what it was 12 months ago? (Go To: 4802) |
| | | Permissible Values (value): | The same (1) |
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| | | | Slightly reduced (about 75% of normal) (3) |
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| | | | Moderately reduced (about 50% of normal) (4) |
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| | | | Markedly reduced (about 25% of normal or less) (5) |
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| * 4802 | Have you experienced fatigue, breathlessness, and/or chest pain? (Go To: 1045) |
| | | Permissible Values (value): | No (0) |
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| * 4803 | Which of the following describes your ability to carry out your usual activities? (Go To: 1045) |
| | | Permissible Values (value): | I am able to carry out my usual activities. (1) |
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| | | | I can carry out my usual activities with effort. (2) |
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| | | | I am unable to carry out my usual activities. (3) |
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| * 1045 | Performance status (Which of the following options would you say describes your current performance status?) (Go To: 1097) |
| | | Permissible Values (value): | Fully active, able to carry on all pre-disease performance without restriction (0) |
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| | | | Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work (1) |
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| | | | Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours (2) |
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| | | | Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (3) |
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| | | | Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair (4) |
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| 1097 | Comments (do not include any participant identifiers) (Go To: End of Form) |