Institution
Item
Institution
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Patient'sName
Item
Patient's Name
text
Patient'sI.D.No.
Item
Patient's I.D. No.
text
Ifthisisarevisedorcorrectedform,indicatebycheckingbox.
Item
If this is a revised or corrected form, indicate by checking box. (Time Point of Assessment)
text
Baseline/Prert
Item
Baseline/Prert
text
Item
Month During Follow-up (HVLT Administration)
text
Code List
Month During Follow-up (HVLT Administration)
Item
Code reason test not done
text
Code List
Code reason test not done
CL Item
Test Omitted, Patient Unable To Comprehend Instructions (Test omitted, patient unable to comprehend instructions)
CL Item
Test Omitted, Patient Refused (Test omitted, patient refused)
CL Item
Test Omitted Due To Institution/investigator Error (Test omitted due to institution/investigator error)
CL Item
Other Reason Test Omitted Specify (Other reason test omitted specify)
CL Item
Reason Unknown (Reason unknown)
Otherreasontestomittedspecify
Item
Other reason test omitted specify (HVLT Results)
text
Trial#1,#2,#3Recall,TotalScore
Item
Trial #1, #2, #3 Recall, Total Score
text
Trial#4Recognition,TotalScore
Item
Trial #4 Recognition, Total Score
text
Timetestcompleted
Item
Time test completed
text
Trial#5DelayedRecall,StartTime
Item
Trial #5 Delayed Recall, Start Time
text
Trial#5DelayedRecall,TotalScore
Item
Trial #5 Delayed Recall, Total Score
text
Comments
Item
Comments
text
Signature
Item
Signature
text
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)