ICHOM Patient Centered Outcomes Measure Set for Breast Cancer
1.0.0 - trial-use

ICHOM Patient Centered Outcomes Measure Set for Breast Cancer, published by HL7 International - Clinical Interoperability Council Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/fhir-ichom-breast-cancer-ig/ and changes regularly. See the Directory of published versions

## Questionnaire: PatientReportedBaseline (Experimental)

Official URL: http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/PatientReportedBaseline | Version: 1.0.0
Standards status: Informative | Computable Name: PatientReportedBaseline

Patient-reported response at baseline (first doctors’ visit)

Structure

LinkId | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
PatientReportedBaseline | Patient-reported response at baseline (first doctors' visit) |  | Questionnaire | http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/PatientReportedBaseline#1.0.0
General-Information-Clinical | General information | 1..1 | group |
NA-Clinical | What is your medical record number? | 1..1 | string |
LastName-Clinical | What is your last name? | 1..1 | string |
Demographics | Demographic factors | 1..1 | group |
Sex | Please indicate your sex at birth | 1..1 | choice | Value Set: AdministrativeGender
COUNTRY | What is your country of residence? | 1..1 | choice | Value Set: Iso 3166 Part 1: 3 Letter Codes
Ethnicity | Please indicate the ethnicity that you identify with | 1..1 | choice | Value Set: Ethnicity
Race | Please indicate the biological race that you identify with | 1..1 | choice | Value Set: Race
EducationLevel | Please indicate your highest level of schooling | 1..1 | choice | Value Set: Education level of patient ValueSet
RelationshipStatus | Please indicate your current relationship status | 1..1 | choice | Value Set: Relationship status of patient ValueSet
MENOPAUSE | Please indicate your current menopausal status | 1..1 | choice | Enable When: Sex = Female (AdministrativeGender#female) Value Set: Menopausal status of patient ValueSet
Baseline-Clinical-Factors | Clinical factors | 1..1 | group |
ComorbiditiesSACQ | Have you been told by a doctor that you have any of the following? | 1..* | choice | Value Set: SACQ Patient's comorbidity history ValueSet
ComorbiditiesSACQ_HeartDiseaseFU1 | Do you receive treatment for heart disease (For example, angina, heart failure, or heart attack)? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Heart disease (SNOMED CT#56265001)
ComorbiditiesSACQ_HeartDiseaseFU2 | Does your heart disease limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Heart disease (SNOMED CT#56265001)
ComorbiditiesSACQ_HighBloodPressureFU1 | Do you receive treatment for high blood pressure? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = High blood pressure (SNOMED CT#38341003)
ComorbiditiesSACQ_HighBloodPressureFU2 | Does your high blood pressure limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = High blood pressure (SNOMED CT#38341003)
ComorbiditiesSACQ_LungDiseaseFU1 | Do you receive treatment for lung disease? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Lung disorder (SNOMED CT#19829001)
ComorbiditiesSACQ_LungDiseaseFU2 | Does your lung disease limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Lung disorder (SNOMED CT#19829001)
ComorbiditiesSACQ_DiabetesFU1 | Do you receive treatment for diabetes? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Diabetes mellitus (SNOMED CT#73211009)
ComorbiditiesSACQ_DiabetesFU2 | Does your diabetes limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Diabetes mellitus (SNOMED CT#73211009)
ComorbiditiesSACQ_StomachDiseaseFU1 | Do you receive treatment for an ulcer or stomach disease? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Disorder of stomach (SNOMED CT#29384001)
ComorbiditiesSACQ_StomachDiseaseFU2 | Does your ulcer or stomach disease limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Disorder of stomach (SNOMED CT#29384001)
ComorbiditiesSACQ_KidneyDiseaseFU1 | Do you receive treatment for kidney disease? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Kidney disease (SNOMED CT#90708001)
ComorbiditiesSACQ_KidneyDiseaseFU2 | Does your kidney disease limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Kidney disease (SNOMED CT#90708001)
ComorbiditiesSACQ_LiverDiseaseFU1 | Do you receive treatment for liver disease? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Hepatopathy (SNOMED CT#235856003)
ComorbiditiesSACQ_LiverDiseaseFU2 | Does your liver disease limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Hepatopathy (SNOMED CT#235856003)
ComorbiditiesSACQ_BloodDiseaseFU1 | Do you receive treatment for anemia or other blood disease? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Disorder of cellular component of blood (disorder) (SNOMED CT#414022008)
ComorbiditiesSACQ_BloodDiseaseFU2 | Does your anemia or other blood disease limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Disorder of cellular component of blood (disorder) (SNOMED CT#414022008)
ComorbiditiesSACQ_CancerFU1 | Do you receive treatment for cancer/another cancer? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Malignant tumour (SNOMED CT#363346000)
ComorbiditiesSACQ_CancerFU2 | Does your cancer/other cancer limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Malignant tumour (SNOMED CT#363346000)
ComorbiditiesSACQ_DepressionFU1 | Do you receive treatment for depression? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Depressive disorder (SNOMED CT#35489007)
ComorbiditiesSACQ_DepressionFU2 | Does your depression limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Depressive disorder (SNOMED CT#35489007)
ComorbiditiesSACQ_OsteoarthritisFU1 | Do you receive treatment for osteoarthritis/degenerative arthritis? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Osteoarthritis (disorder) (SNOMED CT#396275006)
ComorbiditiesSACQ_OsteoarthritisFU2 | Does your osteoarthritis/degenerative arthritis limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Osteoarthritis (disorder) (SNOMED CT#396275006)
ComorbiditiesSACQ_BackPainFU1 | Do you receive treatment for back pain? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Backache (SNOMED CT#161891005)
ComorbiditiesSACQ_BackPainFU2 | Does your back pain limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Backache (SNOMED CT#161891005)
ComorbiditiesSACQ_RheumatoidArthritisFU1 | Do you receive treatment for rheumatoid arthritis? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Rheumatoid arthritis (SNOMED CT#69896004)
ComorbiditiesSACQ_RheumatoidArthritisFU2 | Does your rheumatoid arthritis limit your activities? | 0..1 | boolean | Enable When: ComorbiditiesSACQ = Rheumatoid arthritis (SNOMED CT#69896004)
ComorbiditiesSACQ_Other | What other medical problems are you experiencing? | 0..1 | text | Enable When: ComorbiditiesSACQ = other (NullFlavor#OTH)
Treatment-Variables | Treatment Variables | 1..1 | group |
PatientEducation | Did you feel you received sufficient information about your treatment options? | 1..1 | choice | Value Set: Patient Treatment Education ValueSet
Degree-of-Health-EORTC-QLQ | Degree of Health - EORTC-QLQ | 0..1 | group |
EORTCQLQ-Question01-05 | We are interested in some things about you and your health. Please answer all of the questions yourself by selecting the answer that best applies to you. There are no 'right' or 'wrong' answers. The information that you provide will remain strictly confidential. | 0..1 | group |
EORTCQLQC30_Q01 | Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q02 | Do you have any trouble taking a long walk? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q03 | Do you have any trouble taking a short walk outside of the house? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q04 | Do you need to stay in bed or a chair during the day? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q05 | Do you need help with eating, dressing, washing yourself or using the toilet? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question06-28 | During the past week: | 0..1 | group |
EORTCQLQC30_Q06 | Were you limited in doing either your work or other daily activities? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q07 | Were you limited in pursuing your hobbies or other leisure time activities? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q08 | Were you short of breath? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q09 | Have you had pain? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q10 | Did you need to rest? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q11 | Have you had trouble sleeping? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q12 | Have you felt weak? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q13 | Have you lacked appetite? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q14 | Have you felt nauseated? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q15 | Have you vomited? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q16 | Have you been constipated? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q17 | Have you had diarrhea? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q18 | Were you tired? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q19 | Did pain interfere with your daily activities? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q20 | Have you had difficulty in concentrating on things, like reading a newspaper or watching television? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q21 | Did you feel tense? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q22 | Did you worry? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q23 | Did you feel irritable? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q24 | Did you feel depressed? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q25 | Have you had difficulty remembering things? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q26 | Has your physical condition or medical treatment interfered with your family life? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q27 | Has your physical condition or medical treatment interfered with your social activities? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q28 | Has your physical condition or medical treatment caused you financial difficulties? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question29-30 | For the following questions please select the number between 1 and 7 that best applies to you, with 1 = Very poor and 7 = Excellent. | 0..1 | group |
EORTCQLQC30_Q29 | How would you rate your overall health during the past week? | 1..1 | choice | Options: 7 options
EORTCQLQC30_Q30 | How would you rate your overall quality of life during the past week? | 1..1 | choice | Options: 7 options
EORTCQLQ-Question31-43 | Patients sometimes report that they have the following symptoms or problems. Please indicate the extent to which you have experienced these symptoms or problems during the past week. Please answer by selecting the answer that best applies to you. During the past week: | 0..1 | group |
EORTCQLQBR45_Q31 | Have you had dry mouth? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q32 | Have food and drink tasted different than usual? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q33 | Have your eyes been painful, irritated or watery? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q34 | Have you lost any hair? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q35 | Have you been upset by the loss of your hair? | 0..1 | choice | Enable When: EORTCQLQBR45_Q34 != Not at all (Agreement response CodeSystem#no) Value Set: Agreement response ValueSet
EORTCQLQBR45_Q36 | Have you felt ill or unwell? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q37 | Have you had hot flushes? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q38 | Have you had headaches? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q39 | Have you felt physically less attractive as a result of your disease or treatment? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q40 | Have you felt less feminine as a result of your disease or treatment? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q41 | Have you had problems looking at yourself naked? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q42 | Have you been dissatisfied with your body? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q43 | Have you worried about your health in the future? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question44-46 | During the past four weeks: | 0..1 | group |
EORTCQLQBR45_Q44 | Have you been sexually active? (with or without intercourse) | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q45 | To what extent were you sexually active? (with or without intercourse) | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q46 | Has sex been enjoyable for you? | 0..1 | choice | Enable When: EORTCQLQBR45_Q45 != Not at all (Agreement response CodeSystem#no) Value Set: Agreement response ValueSet
EORTCQLQ-Question47-69 | During the past week: | 0..1 | group |
EORTCQLQBR45_Q48 | Have you had a swollen arm or hand? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q49 | Have you had problems raising your arm or moving it sideways? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q50 | Have you had any pain in the area of your affected breast? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q51 | Has the area of your affected breast been swollen? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q52 | Has the area of your affected breast been oversensitive? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q53 | Have you had skin problems on or in the area of your affected breast (e.g., itchy, dry, flaky)? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q54 | Have you sweated excessively? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q55 | Have you had mood swings? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q56 | Have you been dizzy? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q57 | Have you had soreness in your mouth? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q58 | Have you had any reddening in your mouth? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q59 | Have you had pain in your hands or feet? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q60 | Have you had any redenning on your hands or feet? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q61 | Have you had tingling in your fingers or toes? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q62 | Have you had numbness in your fingers or toes? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q63 | Have you had problems with your joints? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q64 | Have you had stiffness in your joints? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q65 | Have you had pain in your joints? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q66 | Have you had aches or pains in your bones? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q67 | Have you had aches or pains in your muscles? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q68 | Have you gained weight? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q69 | Has weight gain been a problem for you? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question70-71 | During the past four weeks: | 0..1 | group |
EORTCQLQBR45_Q70 | Have you had a dry vagina? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q71 | Have you had discomfort in your vagina? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question72-73 | Please answer the following two questions only if you have been sexually active: | 0..1 | group |
EORTCQLQBR45_Q72 | Have you had pain in your vagina during sexual activity? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q73 | Have you experienced a dry vagina during sexual activity? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question74-75 | During the past week: | 0..1 | group |
EORTCQLQBR45_Q74 | Have you been satisfied with the cosmetic result of the surgery? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q75 | Have you been satisfied with the appearance of the skin of your affected breast (thoracic area)? | 1..1 | choice | Value Set: Agreement response ValueSet
Degree-of-Health-BreastQ | Degree of Health - BreastQ: | 0..1 | group |
IntroBreastQ | With your breasts in mind, or if you have had a mastectomy, with your breast area in mind, in the past 2 weeks, how satisfied or dissatisfied have you been with: | 0..1 | group |
BREASTQMAST_Q01 | How you look in the mirror clothed? | 1..1 | choice | Value Set: Satisfaction response ValueSet
BREASTQMAST_Q02 | How comfortable your bras fit? | 1..1 | choice | Value Set: Satisfaction response ValueSet
BREASTQMAST_Q03 | Being able to wear clothing that is more fitted? | 1..1 | choice | Value Set: Satisfaction response ValueSet
BREASTQMAST_Q04 | How you look in the mirror unclothed? | 1..1 | choice | Value Set: Satisfaction response ValueSet
Documentation for this format

Option Sets

Answer options for EORTCQLQC30_Q29

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Answer options for EORTCQLQC30_Q30

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