PatientInitials
Item
Patient Initials
text
PatientHospitalNo.
Item
Patient Hospital No.
text
Institution/Affiliate
Item
Institution/Affiliate
text
ParticipatingGroup
Item
Participating Group
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
InterviewerorCRA
Item
Interviewer or CRA
text
Item
Assessment Number
text
Code List
Assessment Number
Item
I have numbness or tingling in my hands
text
Code List
I have numbness or tingling in my hands
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have numbness or tingling in my feet
text
Code List
I have numbness or tingling in my feet
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I feel discomfort in my hands
text
Code List
I feel discomfort in my hands
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have discomfort in my feet
text
Code List
I have discomfort in my feet
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have joint pain or muscles cramps
text
Code List
I have joint pain or muscles cramps
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I feel weak all over
text
Code List
I feel weak all over
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have trouble hearing
text
Code List
I have trouble hearing
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I get ringing or buzzing in my ears
text
Code List
I get ringing or buzzing in my ears
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have trouble buttoning buttons
text
Code List
I have trouble buttoning buttons
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have trouble feeling the shape of small objects when they are in my hand.
text
Code List
I have trouble feeling the shape of small objects when they are in my hand.
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have trouble walking.
text
Code List
I have trouble walking.
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)