Item
Mental assessments:Attention Abnormality Present
text
C1444362 (UMLS CUI [1])
Code List
Mental assessments:Attention Abnormality Present
Attention Abnormality Present
Item
Attention Abnormality Present: please specify
text
C0238707 (UMLS CUI [1])
Item
Working memory Abnormality Present
integer
C0025265 (UMLS CUI [1])
Code List
Working memory Abnormality Present
Working memory Abnormality Present
Item
Working memory Abnormality Present:please specify
text
C0561734 (UMLS CUI [1])
Item
Recent (Episodic) Memory Abnormality Present
integer
C0561843 (UMLS CUI [1])
Code List
Recent (Episodic) Memory Abnormality Present
Recent (Episodic) Memory Abnormality Present
Item
Recent (Episodic) Memory Abnormality Present: please specify
text
C0233805 (UMLS CUI [1])
Item
Remote (Semantic) Memory Abnormality Present
integer
C0233793 (UMLS CUI [1])
Code List
Remote (Semantic) Memory Abnormality Present
Remote (Semantic) Memory Abnormality Present
Item
Remote (Semantic) Memory Abnormality Present:please specify
text
C0233806 (UMLS CUI [1])
Item
Language Spontaneous speech Abnormality Present
integer
C0855217 (UMLS CUI [1])
Code List
Language Spontaneous speech Abnormality Present
Language Spontaneous speech Abnormality Present
Item
Language Spontaneous speech Abnormality Present:please specify
text
C0855217 (UMLS CUI [1])
Item
Language comprehension Abnormality Present
integer
C0233733 (UMLS CUI [1])
Code List
Language comprehension Abnormality Present
Language comprehension Abnormality Present
Item
Language comprehension Abnormality Present:please specify
text
C0239083 (UMLS CUI [1])
Item
Naming Abnormality Present
integer
C0233735 (UMLS CUI [1])
Code List
Naming Abnormality Present
Naming Abnormality Present
Item
Naming Abnormality Present:please specify
text
C0233736 (UMLS CUI [1])
Item
Repetition Abnormality Present
integer
C0589243 (UMLS CUI [1])
Code List
Repetition Abnormality Present
Repetition Abnormality Present
Item
Repetition Abnormality Present:please specify
text
C0233742 (UMLS CUI [1])
Item
Reading Abnormality Present
integer
C0586742 (UMLS CUI [1])
Code List
Reading Abnormality Present
Reading Abnormality Present
Item
Reading Abnormality Present:please specify
text
C0586742 (UMLS CUI [1])
Item
Affect Abnormality Present
integer
C0001721 (UMLS CUI [1])
Code List
Affect Abnormality Present
Affect Abnormality Present
Item
Affect Abnormality Present:please specify
text
C0814063 (UMLS CUI [1])
Item
Muscle Bulk global assessment
integer
C0242692 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Code List
Muscle Bulk global assessment
CL Item
Cannot assess, explain (3)
Muscle Bulk global assessment
Item
Muscle Bulk global assessment: if cannot be assessed, please specify
text
C0242692 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Item
Muscle Bulk global assessment: if abnormal, please specify type
integer
C0242692 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Code List
Muscle Bulk global assessment: if abnormal, please specify type
CL Item
Abnormal and symmetric (1)
CL Item
Abnormal and asymmetric (2)
Item
Right upper extremity Abnormality
integer
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right upper extremity Abnormality
CL Item
Cannot assess, explain (3)
Item
Right upper extremity if abnormal,please specify type
integer
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right upper extremity if abnormal,please specify type
CL Item
Abnormal–Decreased (1)
CL Item
Other, specify (2)
Right upper extremity Abnormality
Item
Right upper extremity Abnormality if cannot be assessed, please specify
text
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Right upper extremity Abnormality
Item
Right upper extremity Abnormality:if other please specify
text
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left upper extremity Abnormality
integer
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Code List
Left upper extremity Abnormality
CL Item
Cannot assess, explain (3)
Left upper extremity Abnormality
Item
Left upper extremity Abnormality:if cannot be assessed please specify
text
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Item
Left upper extremity if abnormal, please specify type
integer
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Code List
Left upper extremity if abnormal, please specify type
CL Item
Abnormal–Decreased (1)
CL Item
Other, specify (2)
Left upper extremity Abnormality
Item
Left upper extremity Abnormality:if other please specify
text
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Item
Right lower extremity Abnormality
integer
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right lower extremity Abnormality
CL Item
Cannot assess, explain (3)
Right lower extremity Abnormality
Item
Right lower extremity Abnormality:if cannot be assessed please specify
text
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Right lower extremity if abnormal, please specify type
integer
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right lower extremity if abnormal, please specify type
CL Item
Abnormal–Decreased (1)
CL Item
Other, specify (2)
Right lower extremity Abnormality
Item
Right lower extremity Abnormality:if other,please specify
text
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left lower extremity Abnormality
integer
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Left lower extremity Abnormality
CL Item
Cannot assess, explain (3)
Left lower extremity Abnormality
Item
Left lower extremity Abnormality:if cannot be assessed, please specify
text
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left lower extremity if abnormal, please specify type
integer
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Left lower extremity if abnormal, please specify type
CL Item
Abnormal–Decreased (1)
CL Item
Other, specify (2)
Left lower extremity Abnormality
Item
Left lower extremity Abnormality: if other,please specify
text
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Muscle Tone global assessment
integer
C0026841 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Code List
Muscle Tone global assessment
CL Item
Cannot assess, explain (3)
Muscle Tone global assessment
Item
Muscle Tone global assessment: if cannot be assessed, please specify
text
C0026841 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Item
Muscle Tone global assessment if abnormal, please specify type
integer
C0026841 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Code List
Muscle Tone global assessment if abnormal, please specify type
CL Item
Abnormal and symmetric (1)
CL Item
Abnormal and asymmetric (2)
Item
Right upper extremity muscle tone abnormality
integer
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right upper extremity muscle tone abnormality
CL Item
Cannot assess, explain (3)
Right upper extremity muscle tone abnormality
Item
Right upper extremity muscle tone abnormality:if cannot be assessed, please specify
text
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Right upper extremity muscle tone if abnormal, please specify type
integer
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right upper extremity muscle tone if abnormal, please specify type
CL Item
Abnormal–Increased (1)
CL Item
Other, specify (2)
Right upper extremity muscle tone abnormality
Item
Right upper extremity muscle tone abnormality: if other, please specify
text
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left upper extremity muscle tone abnormality
integer
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Code List
Left upper extremity muscle tone abnormality
CL Item
Cannot assess, explain (3)
Left upper extremity muscle tone abnormality
Item
Left upper extremity muscle tone abnormality:if cannot be assessed, please specify
text
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Item
Left upper extremity muscle tone if abnormal, please specify type
integer
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Code List
Left upper extremity muscle tone if abnormal, please specify type
CL Item
Abnormal–Increased (1)
CL Item
Other, specify (2)
Left upper extremity muscle tone abnormality
Item
Left upper extremity muscle tone abnormality:if other,please specify
text
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Item
Right lower extremity muscle tone abnormality
integer
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right lower extremity muscle tone abnormality
CL Item
Cannot assess, explain (3)
Right lower extremity muscle tone abnormality
Item
Right lower extremity muscle tone abnormality: if cannot be assessed, please specify
text
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Right lower extremity muscle tone if abnormal, please specify type
integer
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right lower extremity muscle tone if abnormal, please specify type
CL Item
Abnormal–Increased (1)
CL Item
Other, specify (2)
Right lower extremity muscle tone abnormality
Item
Right lower extremity muscle tone abnormality:if other, please specify
text
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left lower extremity muscle tone abnormality
integer
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Left lower extremity muscle tone abnormality
CL Item
Cannot assess, explain (3)
Left lower extremity muscle tone abnormality
Item
Left lower extremity muscle tone abnormality:if cannot be assessed, please specify
text
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left lower extremity muscle tone if abnormal, please specify type
integer
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Left lower extremity muscle tone if abnormal, please specify type
CL Item
Abnormal–Increased (1)
CL Item
Other, specify (2)
Left lower extremity muscle tone abnormality
Item
Left lower extremity muscle tone abnormality: if other, please specify
text
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Truncal tone abnormality
integer
C0026841 (UMLS CUI [1,1])
C0460005 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Code List
Truncal tone abnormality
CL Item
Cannot assess, explain (3)
Truncal tone abnormality
Item
Truncal tone abnormality:if cannot be assessed, please specify
text
C0026841 (UMLS CUI [1,1])
C0460005 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Item
Truncal tone if abnormal, please specify type
integer
C0026841 (UMLS CUI [1,1])
C0460005 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Code List
Truncal tone if abnormal, please specify type
CL Item
Abnormal–Increased (1)
CL Item
Abnormal–Decreased (2)
CL Item
Other, specify (3)
Truncal tone abnormality
Item
Truncal tone abnormality: if other, please specify
text
C0026841 (UMLS CUI [1,1])
C0460005 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
Item
Muscle Strength global assessment
integer
C0517349 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Code List
Muscle Strength global assessment
CL Item
Cannot assess, explain (3)
Muscle Strength global assessment
Item
Muscle Strength global assessment:if cannot be assessed, please specify
text
C0517349 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Item
Muscle Strength global assessment: if abnormal,please specify type
integer
C0517349 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Code List
Muscle Strength global assessment: if abnormal,please specify type
CL Item
Abnormal and symmetric (1)
CL Item
Abnormal and asymmetric (2)
Item
Right upper extremity muscle strength abnormality
integer
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right upper extremity muscle strength abnormality
CL Item
Cannot assess, explain (3)
Right upper extremity muscle strength abnormality
Item
Right upper extremity muscle strength abnormality:if cannot be assessed, please specify
text
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Right upper extremity muscle strength if abnormal,please specify type
integer
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right upper extremity muscle strength if abnormal,please specify type
CL Item
Abnormal–Decreased (1)
CL Item
Other, specify (2)
Right upper extremity muscle strength abnormality
Item
Right upper extremity muscle strength abnormality:if other, please specify
text
C0230329 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left upper extremity muscle strength abnormality
integer
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Code List
Left upper extremity muscle strength abnormality
CL Item
Cannot assess, explain (3)
Left upper extremity muscle strength abnormality
Item
Left upper extremity muscle strength abnormality:if cannot be assessed, please specify
text
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Item
Left upper extremity muscle strength if abnormal, please specify type
integer
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Code List
Left upper extremity muscle strength if abnormal, please specify type
CL Item
Abnormal–Decreased (1)
CL Item
Other, specify (2)
Left upper extremity muscle strength abnormality
Item
Left upper extremity muscle strength abnormality:if other, please specify
text
C0031809 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Item
Right lower extremity muscle strength abnormality
integer
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right lower extremity muscle strength abnormality
CL Item
Cannot assess, explain (3)
Right lower extremity muscle strength abnormality
Item
Right lower extremity muscle strength abnormality:if cannot be assessed, please specify
text
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Right lower extremity muscle strength if abnormal, please specify type
integer
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Right lower extremity muscle strength if abnormal, please specify type
CL Item
Abnormal–Decreased (1)
CL Item
Other, specify (2)
Right lower extremity muscle strength abnormality
Item
Right lower extremity muscle strength abnormality:if other,please specify
text
C0230415 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left lower extremity muscle strength abnormality
integer
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Left lower extremity muscle strength abnormality
CL Item
Cannot assess, explain (3)
Left lower extremity muscle strength abnormality
Item
Left lower extremity muscle strength abnormality:if cannot be assessed, please specify
text
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
Left lower extremity muscle strength if abnormal, please specify type
integer
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Left lower extremity muscle strength if abnormal, please specify type
CL Item
Abnormal–Decreased (1)
CL Item
Other, specify (2)
Left lower extremity muscle strength abnormality
Item
Left lower extremity muscle strength abnormality:if other, please specify
text
C0230416 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Weakness
Item
Weakness
boolean
C0151786 (UMLS CUI [1])
Item
Does the weakness suggest one of the following patterns?
integer
C0151786 (UMLS CUI [1])
Code List
Does the weakness suggest one of the following patterns?
CL Item
Right Hemiparesis (1)
CL Item
Left Hemiparesis (2)
CL Item
Diplegia/Paraparesis (3)
CL Item
Quadriplegia/Quadraparesis (4)
CL Item
Peripheral Nerve Lesion(s), describe (5)
CL Item
Neuropathic Weakness, describe (6)
CL Item
Myopathic Weakness, describe (7)
CL Item
Other, specify (8)
Weakness
Item
Weakness,if applicable please describe further
text
C0151786 (UMLS CUI [1])
Item
Specify the neurological location of the weakness
integer
C0151786 (UMLS CUI [1])
Code List
Specify the neurological location of the weakness
CL Item
Peripheral Nervous System (3)
CL Item
Other, specify (4)
Weakness
Item
If other neurological location, please specify
text
C0151786 (UMLS CUI [1])
Item
Tremor
integer
C0040822 (UMLS CUI [1])
CL Item
Cannot Assess, explain (3)
CL Item
Other, specify (4)
Tremor
Item
Tremor, if applicable please specify or explain further
text
C0040822 (UMLS CUI [1])
Item
Type of tremor
integer
C0040822 (UMLS CUI [1])
CL Item
Other, specify (4)
Tremor
Item
If other type of tremor,please specify
text
C0040822 (UMLS CUI [1])
Date
Item
Date of examination:
date
C0011008 (UMLS CUI [1])
Item
If follow-up exam, change from prior exam
integer
C0589120 (UMLS CUI [1])
Code List
If follow-up exam, change from prior exam
CL Item
Other, specify (5)
Follow up
Item
If other change from prior exam, please specify
text
C0589120 (UMLS CUI [1])
Item
Tanner Stage
integer
C2197575 (UMLS CUI [1])
C2197573 (UMLS CUI [2])
C0429602 (UMLS CUI [3])
C0429596 (UMLS CUI [4])
Item
Handedness
integer
C0023114 (UMLS CUI [1])
Item
Constitutional symptoms (e.g., fever, weight loss)
integer
C0009812 (UMLS CUI [1])
Code List
Constitutional symptoms (e.g., fever, weight loss)
Item
Eyes
integer
C0015392 (UMLS CUI [1])
Item
Ears, Nose, Mouth, and Throat
integer
C0553490 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Code List
Ears, Nose, Mouth, and Throat
Item
Cardiovascular
integer
C0007226 (UMLS CUI [1])
Item
Respiratory
integer
C0035237 (UMLS CUI [1])
Item
Gastrointestinal
integer
C0012240 (UMLS CUI [1])
Code List
Gastrointestinal
Item
Genitourinary
integer
C0042066 (UMLS CUI [1])
Item
Musculoskeletal
integer
C0026860 (UMLS CUI [1])
Code List
Musculoskeletal
Item
Integumentary (skin and/or breast)
integer
C0037267 (UMLS CUI [1])
Code List
Integumentary (skin and/or breast)
Item
Neurological
integer
C0027763 (UMLS CUI [1])
Item
Psychiatric
integer
C0846574 (UMLS CUI [1])
Item
Endocrine system
integer
C0014136 (UMLS CUI [1])
Code List
Endocrine system
Item
Hematologic/Lymphatic
integer
C1442298 (UMLS CUI [1])
Code List
Hematologic/Lymphatic
Item
Allergic/Immunologic
integer
C0021053 (UMLS CUI [1,1])
C0020517 (UMLS CUI [1,2])
Code List
Allergic/Immunologic
Constitutional symptoms
Item
Constitutional symptoms (e.g., fever, weight loss): Please specify any abnormality or if not examined
text
C0009812 (UMLS CUI [1])
Eyes
Item
Eyes: please specify any abnormality or if not examined
text
C0015392 (UMLS CUI [1])
Ears, Nose, Mouth, and Throat
Item
Ears, Nose, Mouth, and Throat: please specify any abnormality or if not examined
text
C0553490 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Cardiovascular
Item
Cardiovascular:Please specify any abnormality or if not examined
text
C0007226 (UMLS CUI [1])
Respiratory
Item
Respiratory:Please specify any abnormality or if not examined
text
C0035237 (UMLS CUI [1])
Gastrointestinal
Item
Gastrointestinal: please specify any abnormality or if not examined
text
C0012240 (UMLS CUI [1])
Genitourinary
Item
Genitourinary:please specify any abnormality or if not examined
text
C0042066 (UMLS CUI [1])
Musculoskeletal
Item
Musculoskeletal: Please specify any abnormality or if not examined
text
C0026860 (UMLS CUI [1])
Integumentary
Item
Integumentary (skin and/or breast):Please specify any abnormality or if not examined
text
C0037267 (UMLS CUI [1])
Neurological
Item
Neurological: Please specify any abnormality or if not examined
text
C0027763 (UMLS CUI [1])
Psychiatric
Item
Psychiatric:Please specify any abnormality or if not examined
text
C0846574 (UMLS CUI [1])
Endocrine
Item
Endocrine system: please specify any abnormality or if not examined
text
C0014136 (UMLS CUI [1])
Hematologic/Lymphatic
Item
Hematologic/Lymphatic:Please specify any abnormality or if not examined
text
C1442298 (UMLS CUI [1])
Allergic/Immunologic
Item
Allergic/Immunologic: please specify abnormality or if not examined
text
C0021053 (UMLS CUI [1,1])
C0020517 (UMLS CUI [1,2])