Bristol CT/MRI Reporting Form 1: Diagnostic Staging

{"elements":[{"isDiscrete":false,"hidden":false,"name":"Patient_Trial_Number (3-digit)","readOnly":false,"id":69409460,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"Patient_Initials_(If known)","readOnly":false,"id":69409461,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"Scan_Transfer_Report_Code_(4-digit) ","readOnly":false,"id":69409462,"type":"textFieldElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Aberdeen Royal Infirmary","value":"0-aberdeenroyalinfirmary"},{"text":"Basildon University Hospital","value":"1-basildonuniversityhospital"},{"text":"Beatson West of Scotland Cancer care Centre","value":"2-beatsonwestofscotlandcancercarecentre"},{"text":"Belfast City Hospital","value":"3-belfastcityhospital"},{"text":"Blackpool Victoria Hospital","value":"4-blackpoolvictoriahospital"},{"text":"Bradford Royal infirmary","value":"5-bradfordroyalinfirmary"},{"text":"Bristol Haematology and Oncology Centre","value":"6-bristolhaematologyandoncologycentre"},{"text":"Burnley General Hospital","value":"7-burnleygeneralhospital"},{"text":"Castle Hill Hospital","value":"8-castlehillhospital"},{"text":"Cheltenham General Hospital","value":"9-cheltenhamgeneralhospital"},{"text":"Chesterfield Royal Hospital","value":"10-chesterfieldroyalhospital"},{"text":"Christie Hospital","value":"11-christiehospital"},{"text":"Derriford Hospital","value":"12-derrifordhospital"},{"text":"Dumfries & Galloway","value":"13-dumfriesgalloway"},{"text":"Gloucester Royal Hospital","value":"14-gloucesterroyalhospital"},{"text":"Guy\u0092s Hospital","value":"15-guyshospital"},{"text":"Heartlands Hospital","value":"16-heartlandshospital"},{"text":"James Cook University hospital","value":"17-jamescookuniversityhospital"},{"text":"Kent & Canterbury Hospital","value":"18-kentcanterburyhospital"},{"text":"Luton and Dunstable","value":"19-lutonanddunstable"},{"text":"Manchester Royal Infirmary","value":"20-manchesterroyalinfirmary"},{"text":"Mount Vernon Hospital","value":"21-mountvernonhospital"},{"text":"New Cross Hospital","value":"22-newcrosshospital"},{"text":"North Manchester General Hospital","value":"23-northmanchestergeneralhospital"},{"text":"Nottingham university Hospitals","value":"24-nottinghamuniversityhospitals"},{"text":"Poole Hospital","value":"25-poolehospital"},{"text":"Queen Elizabeth Hospital Birmingham","value":"26-queenelizabethhospitalbirmingham"},{"text":"Queen Elizabeth Queen Mother Hospital Belfast","value":"27-queenelizabethqueenmotherhospitalbelfast"},{"text":"Royal Blackburn Hospital","value":"28-royalblackburnhospital"},{"text":"Royal Derby Hospital","value":"29-royalderbyhospital"},{"text":"Royal Devon & Exeter Hospital","value":"30-royaldevonexeterhospital"},{"text":"Royal Marsden Hospital","value":"31-royalmarsdenhospital"},{"text":"Royal Preston Hospital","value":"32-royalprestonhospital"},{"text":"Royal Surrey County Hospital","value":"33-royalsurreycountyhospital"},{"text":"Royal United Hospital","value":"34-royalunitedhospital"},{"text":"Royal Victoria Hospital","value":"35-royalvictoriahospital"},{"text":"Russell\u0092s Hall Hospital","value":"36-russellshallhospital"},{"text":"Singleton Hospital","value":"37-singletonhospital"},{"text":"Sir Bobby Robson Cancer Trials Research Centre","value":"38-sirbobbyrobsoncancertrialsresearchcentre"},{"text":"Southend University Hospital","value":"39-southenduniversityhospital"},{"text":"Southmead Hospital","value":"40-southmeadhospital"},{"text":"St James\u0092 University Hospital","value":"41-stjamesuniversityhospital"},{"text":"Sunderland Royal hospital","value":"42-sunderlandroyalhospital"},{"text":"Torbay Hospital","value":"43-torbayhospital"},{"text":"University College London Hospital","value":"44-universitycollegelondonhospital"},{"text":"University Hospital Aintree","value":"45-universityhospitalaintree"},{"text":"University Hospitals Coventry and Warwickshire","value":"46-universityhospitalscoventryandwarwickshire"},{"text":"Velindre Cancer Centre","value":"47-velindrecancercentre"},{"text":"Walsall Manor Hospital","value":"48-walsallmanorhospital"},{"text":"Western General Hospital","value":"49-westerngeneralhospital"},{"text":"Weston Park Hospital","value":"50-westonparkhospital"},{"text":"William Harvey Hospital","value":"51-williamharveyhospital"}],"name":"Hospital","readOnly":false,"id":69409463,"type":"listElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"CT","value":"0-ct"},{"text":"MRI","value":"1-mri"},{"text":"Both","value":"2-both"}],"name":"Scan_Type","readOnly":false,"id":69409464,"type":"radioElement"},{"isDiscrete":false,"hidden":false,"name":"Date_of_CT_Scan_(If applicable)","readOnly":false,"id":69409465,"type":"dateTimeElement"},{"isDiscrete":false,"hidden":false,"name":"Date_of_MRI_Scan_(If applicable)","readOnly":false,"id":69409466,"type":"dateTimeElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Tonsil","value":"0-tonsil"},{"text":"Base of Tongue","value":"1-baseoftongue"},{"text":"Floor of mouth","value":"2-floorofmouth"},{"text":"Palate","value":"3-palate"},{"text":"Tongue","value":"4-tongue"},{"text":"Postcricoid","value":"5-postcricoid"},{"text":"Supraglottis","value":"6-supraglottis"},{"text":"Glottis","value":"7-glottis"},{"text":"Subglottis","value":"8-subglottis"},{"text":"Transglottis","value":"9-transglottis"},{"text":"Piriform","value":"10-piriform"},{"text":"Posterior pharyngeal wall","value":"11-posteriorpharyngealwall"}],"name":"Primary_Site_(As recorded by centre/site)","readOnly":false,"id":69409467,"type":"listElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Left","value":"0-left"},{"text":"Right","value":"1-right"},{"text":"Midline","value":"2-midline"}],"name":"Side_of_Primary_Site (As recorded by centre/site)","readOnly":false,"id":69409468,"type":"listElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"T1","value":"0-t1"},{"text":"T2","value":"1-t2"},{"text":"T3","value":"2-t3"},{"text":"T4","value":"3-t4"},{"text":"Occult","value":"4-occult"}],"name":"T_Stage_(As recorded by centre/site)","readOnly":false,"id":69409469,"type":"listElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Right I","value":"0-righti"},{"text":"Right II","value":"1-rightii"},{"text":"Right III","value":"2-rightiii"},{"text":"Right IV","value":"3-rightiv"},{"text":"Right V","value":"4-rightv"},{"text":"Left I","value":"5-lefti"},{"text":"Left II","value":"6-leftii"},{"text":"Left III","value":"7-leftiii"},{"text":"Left IV","value":"8-leftiv"},{"text":"Left V","value":"9-leftv"},{"text":"Midline VI","value":"10-midlinevi"}],"name":"Nodal_Sites_Involved_(As recorded by centre/site)","readOnly":false,"id":69409470,"type":"checkboxElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"N0","value":"0-n0"},{"text":"N1","value":"1-n1"},{"text":"N2a","value":"2-n2a"},{"text":"N2b","value":"3-n2b"},{"text":"N2c","value":"4-n2c"},{"text":"N3","value":"5-n3"}],"name":"N_Stage_(As recorded by centre/site)","readOnly":false,"id":69409471,"type":"listElement"},{"isDiscrete":false,"hidden":false,"name":"Max_dimension_of_largest_Left_Node_(As recorded by centre/site)","readOnly":false,"id":69409472,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"Maximum_dimension_of_largest_Right_Node_(As recorded by centre/site)","readOnly":false,"id":69409473,"type":"textFieldElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Yes","value":"0-yes"},{"text":"No","value":"1-no"},{"text":"Not assessed","value":"2-notassessed"}],"name":"Has_the_centre/site_indicated_that_Distant_Metastases_has_been_detected","readOnly":false,"id":69409474,"type":"checkboxElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Lung","value":"0-lung"},{"text":"Bone","value":"1-bone"},{"text":"Liver","value":"2-liver"},{"text":"Other (please specify below)","value":"3-otherpleasespecifybelow"}],"name":"If Yes Distant Metastases_type","readOnly":false,"id":69409475,"type":"checkboxElement"},{"isDiscrete":false,"hidden":false,"name":"If_other_Metastases_indicate_type","readOnly":false,"id":69409476,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"1319554851142_0.4371778345961682_0.1743047125994659","readOnly":false,"id":69409477,"type":"commentElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Yes","value":"0-yes"},{"text":"No","value":"1-no"}],"name":"Is_the_recorded_Primary_Site_correct","readOnly":false,"id":69409478,"type":"radioElement"},{"isDiscrete":false,"hidden":false,"name":"If_No_correct_Primary_Site","readOnly":false,"id":69409479,"type":"textFieldElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Yes","value":"0-yes"},{"text":"No","value":"1-no"}],"name":"Is_the_recorded_T_Stage_correct","readOnly":false,"id":69409480,"type":"radioElement"},{"isDiscrete":false,"hidden":false,"name":"If_No_correct_T_Stage","readOnly":false,"id":69409481,"type":"textFieldElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Yes","value":"0-yes"},{"text":"No","value":"1-no"}],"name":"Is_the_recorded_N_Stage_correct","readOnly":false,"id":69409482,"type":"radioElement"},{"isDiscrete":false,"hidden":false,"name":"If_No_correct_N_Stage","readOnly":false,"id":69409483,"type":"textFieldElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Yes","value":"0-yes"},{"text":"No","value":"1-no"}],"name":"Are_the_recorded_Distant_Metastases_correct","readOnly":false,"id":69409484,"type":"radioElement"},{"isDiscrete":false,"hidden":false,"name":"If No correct Distant Metastases","readOnly":false,"id":69409485,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"Comments","readOnly":false,"id":69409486,"type":"textBoxElement"},{"isDiscrete":false,"hidden":false,"name":"Form_Completed_By (Name)","readOnly":false,"id":69409487,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"Form_Completion_Date","readOnly":false,"id":69409488,"type":"dateTimeElement"}]}