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 (1)
CL Item
one answer correct (2)
CL Item
no answer correct (3)
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])
