Date of screening
Item
Date of screening for trial
date
C0011008 (UMLS CUI [1,1])
C1710477 (UMLS CUI [1,2])
Patient Study ID
Item
Patient ID
text
C2348585 (UMLS CUI [1])
Item
Consciousness
text
C1697238 (UMLS CUI [1,1])
C0517960 (UMLS CUI [1,2])
CL Item
dazed,reaction to small stimuli 1 (2)
CL Item
stuporous,reaction only to repeated or strong stimuli 2 (3)
Item
Orientation to age and month
text
C1697238 (UMLS CUI [1,1])
C2237121 (UMLS CUI [1,2])
Code List
Orientation to age and month
CL Item
both answers correct 0 (1)
CL Item
no answer correct 2 (2)
CL Item
no answer correct 2 (2)
Item
Request patient to close eyes and to squeeze hand
text
C1697238 (UMLS CUI [1])
Code List
Request patient to close eyes and to squeeze hand
CL Item
followed both requests correctly 0 (1)
CL Item
followed one request correctly 1 (2)
CL Item
followed no request correctly 2 (3)
Item
Eye movement
text
C1697238 (UMLS CUI [1,1])
C0015413 (UMLS CUI [1,2])
CL Item
partial gaze palsy 1 (2)
CL Item
forced deviation (total gaze paresis) 2 (3)
Item
Peripheral vision
text
C1697238 (UMLS CUI [1,1])
C0234628 (UMLS CUI [1,2])
Code List
Peripheral vision
CL Item
partial visual field loss 1 (2)
CL Item
total hemianopsia 2 (3)
CL Item
bilateral hemianopsia or blindness 3 (4)
Item
Facial expression
text
C1697238 (UMLS CUI [1,1])
C0015457 (UMLS CUI [1,2])
Code List
Facial expression
CL Item
little asymmetry 1 (2)
CL Item
partial paresis of lower half of the face 2 (3)
CL Item
total facial paresis 3 (4)
Item
Motor function of arms ( one arm at a time)
text
C1697238 (UMLS CUI [1,1])
C0234130 (UMLS CUI [1,2])
Code List
Motor function of arms ( one arm at a time)
CL Item
right: no dropping 0 (1)
CL Item
right: dropping of arm within 10 sec 1 (2)
CL Item
right:drops arm onto the pad,raise possible against gravity 2 (3)
CL Item
right:no active raise against gravity 3 (4)
CL Item
right:no movement at all 4 (5)
CL Item
right:amputation or joint immobility 9 (6)
CL Item
left: no dropping 0 (7)
CL Item
left: dropping of arm within 10 sec 1 (8)
CL Item
left:drops arm onto the pad,raise possible against gravity 2 (9)
CL Item
left:no active raise against gravity 3 (10)
CL Item
left:no movement at all 4 (11)
CL Item
left:amputation or joint immobility 9 (12)
Item
Motor function of legs (One leg at a time)
text
C1697238 (UMLS CUI [1,1])
C0234130 (UMLS CUI [1,2])
Code List
Motor function of legs (One leg at a time)
CL Item
right: no dropping 0 (1)
CL Item
right: dropping of leg within 10 sec 1 (2)
CL Item
right:drops leg onto the pad,raise possible against gravity 2 (3)
CL Item
right:no active raise against gravity 3 (4)
CL Item
right:no movement at all 4 (5)
CL Item
right:amputation or joint immobility 9 (6)
CL Item
left: no dropping 0 (7)
CL Item
left: dropping of leg within 10 sec 1 (8)
CL Item
left:drops leg onto the pad,raise possible against gravity 2 (9)
CL Item
left:no active raise against gravity 3 (10)
CL Item
left:no movement at all 4 (11)
CL Item
left:amputation or joint immobility 9 (12)
Item
Ataxia
text
C1697238 (UMLS CUI [1,1])
C0004134 (UMLS CUI [1,2])
CL Item
no ataxia or only related to paresis 0 (1)
CL Item
ataxia of one extremity 1 (2)
CL Item
ataxia of two or more extremities 2 (3)
Item
Sensibility
text
C1697238 (UMLS CUI [1,1])
C0439823 (UMLS CUI [1,2])
CL Item
partial loss of sensibility 1 (2)
CL Item
severe or total loss of sensibility 2 (3)
Item
Verbal expression
text
C1697238 (UMLS CUI [1,1])
C0150820 (UMLS CUI [1,2])
Code List
Verbal expression
CL Item
reduced verbal fluency or reduced speech understanding 1 (2)
CL Item
severe aphasia or fragmented verbal expression 2 (3)
CL Item
global aphasia/Muteness 3 (4)
Item
Speech
text
C1697238 (UMLS CUI [1,1])
C0846595 (UMLS CUI [1,2])
CL Item
slurred speech, but still understandable 1 (2)
CL Item
mute or unintelligible/ anarthria 2 (3)
Item
Neglect
text
C1697238 (UMLS CUI [1,1])
C0150088 (UMLS CUI [1,2])
CL Item
partial hemi-neglect of one quality 1 (2)
CL Item
severe hemi-neglect of more than one quality 2 (3)
Item
Other neurologic deficits
text
C1697238 (UMLS CUI [1,1])
C0521654 (UMLS CUI [1,2])
Code List
Other neurologic deficits
Other neurologic deficits
Item
Please specify other neurologic deficits
text
C0521654 (UMLS CUI [1])
Item
Modified Rankin Stroke Scale score
text
C2984908 (UMLS CUI [1])
Code List
Modified Rankin Stroke Scale score
CL Item
No symptoms at all 0 (1)
CL Item
No significant disability despite symptoms; able to carry out all usual duties and activities 1 (2)
CL Item
Slight disability; unable to carry out all previous activities but able to look after own affairs without assistance 2 (3)
CL Item
Moderate disability; requiring some help but able to walk without assistance 3 (4)
CL Item
Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 4 (5)
CL Item
Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 5 (6)
Date of completion
Item
Date of completion of this form
date
C0011008 (UMLS CUI [1])
Signature
Item
Signature by investigator
text
C1519316 (UMLS CUI [1])
Name of Investigator
Item
Name of Investigator
text
C0008961 (UMLS CUI [1])