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Patient questionnaire

1 forms  
  1. StudyEvent: ODM
    1. Patient questionnaire
Patient demographics
Description

Patient demographics

Patient name
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Address
Description

Address

Data type

integer

Alias
UMLS CUI [1]
C0421449
Telephone
Description

Telephone

Data type

integer

Alias
UMLS CUI [1]
C1515258
Relegion
Description

Religion

Data type

text

Alias
UMLS CUI [1]
C0035039
Gender
Description

Gender

Data type

integer

Alias
UMLS CUI [1]
C0079399
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Nationality
Description

Nationality

Data type

integer

Alias
UMLS CUI [1]
C0027473
Family status
Description

Family status

Data type

integer

Alias
UMLS CUI [1]
C0682315
Partner
Description

Partner

Data type

integer

Alias
UMLS CUI [1]
C0682323
In case of partnership
Description

In case of partnership

Data type

integer

Symptoms
Description

Symptoms

Alias
UMLS CUI-1
C1457887
Please state current symptoms
Description

Symptoms

Data type

integer

Alias
UMLS CUI [1]
C1457887
GP
Description

GP

Alias
UMLS CUI-1
C0017319
Name of GP
Description

GP

Data type

text

Alias
UMLS CUI [1]
C0017319
Address
Description

Address

Data type

integer

Alias
UMLS CUI [1]
C0421449
Telephone
Description

Telephone

Data type

integer

Outpatient departement
Description

Outpatient departement

Alias
UMLS CUI-1
C0557824
Who has advised you to come to the outpatient department?
Description

Outpatient department

Data type

integer

Alias
UMLS CUI [1,1]
C0557824
UMLS CUI [1,2]
C0566251
Household
Description

Household

Indicate the Person(s) living with
Description

Household

Data type

integer

Alias
UMLS CUI [1]
C0020052
Living arrangements
Description

Living arrangements

Data type

integer

Alias
UMLS CUI [1]
C0242487
Qualifications
Description

Qualifications

School degree
Description

Höchste(r) erreichte(r) Berufsabschluß/ Berufsausbildung:

Data type

integer

Alias
UMLS CUI [1]
C1709790
Vocational qualification
Description

Vocational qualification

Data type

integer

Alias
UMLS CUI [1]
C0013658
Current occupation
Description

occupation

Data type

integer

Alias
UMLS CUI [1]
C0421456
Who earned the hightest income in your household?
Description

Job

Data type

integer

Alias
UMLS CUI [1]
C0021162
Employable
Description

Employable

Data type

boolean

Retirement
Description

Retirement

Data type

integer

Alias
UMLS CUI [1]
C0035345
severe disability
Description

severe disability

Data type

integer

Alias
UMLS CUI [1]
C0424990
Work Capacity Evaluation
Description

Work Capacity Evaluation

Data type

boolean

Alias
UMLS CUI [1]
C0043228
Family history
Description

Family history

Do you have any children?
Description

Children

Data type

boolean

Alias
UMLS CUI [1]
C0008059
Name of Children
Description

Name of Children

Data type

integer

Alias
UMLS CUI [1]
C0008059
Siblings
Description

Siblings

Data type

boolean

Alias
UMLS CUI [1]
C0037047
Mother
Description

Mother

Data type

integer

Alias
UMLS CUI [1]
C0026591
Father
Description

Father

Data type

integer

Alias
UMLS CUI [1]
C0015671
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Similar models

Patient questionnaire

1 forms
  1. StudyEvent: ODM
    1. Patient questionnaire
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient demographics
Patient name
Item
Patient name
text
C1299487 (UMLS CUI [1])
Address
Item
Address
integer
C0421449 (UMLS CUI [1])
Telephone
Item
Telephone
integer
C1515258 (UMLS CUI [1])
Religion
Item
Relegion
text
C0035039 (UMLS CUI [1])
Item
Gender
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Gender
CL Item
male (1)
C1706180 (UMLS CUI-1)
CL Item
female (2)
C0015780 (UMLS CUI-1)
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Nationality
integer
C0027473 (UMLS CUI [1])
Nationality
Code List
Nationality
CL Item
German (1)
C1556085 (UMLS CUI-1)
CL Item
Other nationality (2)
C0027473 (UMLS CUI-1)
CL Item
late repatriate (3)
Item
Family status
integer
C0682315 (UMLS CUI [1])
Family status
Code List
Family status
CL Item
single (1)
C0037179 (UMLS CUI-1)
CL Item
married (2)
C0555047 (UMLS CUI-1)
CL Item
separated (3)
C0086972 (UMLS CUI-1)
CL Item
divorced (4)
C0086170 (UMLS CUI-1)
CL Item
widowed (5)
C0206275 (UMLS CUI-1)
CL Item
re-married (6)
C2114520 (UMLS CUI-1)
Item
Partner
integer
C0682323 (UMLS CUI [1])
Partner
Code List
Partner
CL Item
no partner (1)
C0420841 (UMLS CUI-1)
CL Item
steady partnership (2)
C1711206 (UMLS CUI-1)
CL Item
promiscuous  (3)
C0562558 (UMLS CUI-1)
CL Item
spouse (4)
C3842295 (UMLS CUI-1)
Item
In case of partnership
integer
In case of partnership
Code List
In case of partnership
CL Item
Date of birth of partner (1)
C0803906 (UMLS CUI-1)
CL Item
Job of partner (2)
C0028811 (UMLS CUI-1)
Item Group
Symptoms
C1457887 (UMLS CUI-1)
Item
Please state current symptoms
integer
C1457887 (UMLS CUI [1])
Symptoms
Code List
Please state current symptoms
CL Item
Symptoms since when? (1)
C3175529 (UMLS CUI-1)
Item Group
GP
C0017319 (UMLS CUI-1)
GP
Item
Name of GP
text
C0017319 (UMLS CUI [1])
Address
Item
Address
integer
C0421449 (UMLS CUI [1])
Telephone
Item
Telephone
integer
Item Group
Outpatient departement
C0557824 (UMLS CUI-1)
Item
Who has advised you to come to the outpatient department?
integer
C0557824 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Outpatient department
Code List
Who has advised you to come to the outpatient department?
CL Item
GP (1)
C0017319 (UMLS CUI-1)
CL Item
Hospital (2)
C0019994 (UMLS CUI-1)
CL Item
consultant (3)
C0545082 (UMLS CUI-1)
C0009817 (UMLS CUI-2)
CL Item
Psychotherapist (4)
C0557555 (UMLS CUI-1)
CL Item
Advice center (5)
CL Item
Partner/ relative / friends (6)
C3887537 (UMLS CUI-1)
CL Item
Myself (7)
CL Item
Other (8)
C0205394 (UMLS CUI-1)
Item Group
Household
Item
Indicate the Person(s) living with
integer
C0020052 (UMLS CUI [1])
Household
Code List
Indicate the Person(s) living with
Item
Living arrangements
integer
C0242487 (UMLS CUI [1])
Living arrangements
Code List
Living arrangements
CL Item
Flat or house (1)
C0457933 (UMLS CUI-1)
CL Item
home for the elderly (2)
C0019870 (UMLS CUI-1)
Item Group
Qualifications
Item
School degree
integer
C1709790 (UMLS CUI [1])
School degree
Code List
School degree
CL Item
no degree (1)
Item
Vocational qualification
integer
C0013658 (UMLS CUI [1])
Vocational qualification
Code List
Vocational qualification
CL Item
Vocational qualification (1)
C1709790 (UMLS CUI-1)
CL Item
University degree (2)
C0041740 (UMLS CUI-1)
CL Item
no qualification (3)
C0007836 (UMLS CUI-1)
CL Item
other (4)
C0205394 (UMLS CUI-1)
Item
Current occupation
integer
C0421456 (UMLS CUI [1])
occupation
Code List
Current occupation
CL Item
worker (1)
C1306056 (UMLS CUI-1)
CL Item
employee (2)
C0599987 (UMLS CUI-1)
CL Item
civil servant (3)
C0401892 (UMLS CUI-1)
CL Item
self-employed (4)
C0425092 (UMLS CUI-1)
CL Item
unemployed (5)
C0041674 (UMLS CUI-1)
Item
Who earned the hightest income in your household?
integer
C0021162 (UMLS CUI [1])
Job
Code List
Who earned the hightest income in your household?
CL Item
I live alone (1)
CL Item
worker (2)
C1306056 (UMLS CUI-1)
CL Item
craftsman (3)
CL Item
employee (4)
C0599987 (UMLS CUI-1)
CL Item
civil servant (5)
C0401892 (UMLS CUI-1)
Employable
Item
Employable
boolean
Item
Retirement
integer
C0035345 (UMLS CUI [1])
Retirement
Code List
Retirement
CL Item
no (1)
C1298908 (UMLS CUI-1)
CL Item
pension application (2)
C0185125 (UMLS CUI-1)
Item
severe disability
integer
C0424990 (UMLS CUI [1])
severe disability
Code List
severe disability
CL Item
no (1)
C1298908 (UMLS CUI-1)
CL Item
yes (2)
C1705108 (UMLS CUI-1)
CL Item
degree (3)
C0449438 (UMLS CUI-1)
C0439792 (UMLS CUI-2)
CL Item
application (4)
C0185125 (UMLS CUI-1)
Work Capacity Evaluation
Item
Work Capacity Evaluation
boolean
C0043228 (UMLS CUI [1])
Item Group
Family history
Children
Item
Do you have any children?
boolean
C0008059 (UMLS CUI [1])
Item
Name of Children
integer
C0008059 (UMLS CUI [1])
Name of Children
Code List
Name of Children
CL Item
First name (1)
C1443235 (UMLS CUI-1)
CL Item
Gender (2)
C0079399 (UMLS CUI-1)
CL Item
Date of birth (3)
C0421451 (UMLS CUI-1)
CL Item
In case of death: Cause of death (4)
C0007465 (UMLS CUI-1)
Siblings
Item
Siblings
boolean
C0037047 (UMLS CUI [1])
Item
Mother
integer
C0026591 (UMLS CUI [1])
Mother
Code List
Mother
CL Item
date of birth (1)
C0421451 (UMLS CUI-1)
CL Item
date of death (2)
C1148348 (UMLS CUI-1)
CL Item
job (3)
C0028811 (UMLS CUI-1)
Item
Father
integer
C0015671 (UMLS CUI [1])
Mother
Code List
Father
CL Item
date of birth (1)
C0421451 (UMLS CUI-1)
CL Item
date of death (2)
C1148348 (UMLS CUI-1)
CL Item
job (3)
C0028811 (UMLS CUI-1)
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