English

Assessments and Examinations

1 forms  
Neurological examination
Description

Neurological examination

Study ID
Description

Study ID

Data type

text

Alias
UMLS CUI [1]
C2826693
Study site name
Description

Study site

Data type

text

Alias
UMLS CUI [1]
C2825164
Subject ID
Description

Subject ID

Data type

text

Alias
UMLS CUI [1]
C2348585
Date of examination:
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
If follow-up exam, change from prior exam
Description

Follow up

Data type

integer

Alias
UMLS CUI [1]
C0589120
If other change from prior exam, please specify
Description

Follow up

Data type

text

Alias
UMLS CUI [1]
C0589120
Mental Status
Description

Mental Status

Mental assessments:Attention Abnormality Present
Description

Mental assessment

Data type

text

Alias
UMLS CUI [1]
C1444362
Attention Abnormality Present: please specify
Description

Attention Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0238707
Working memory Abnormality Present
Description

Working memory

Data type

integer

Alias
UMLS CUI [1]
C0025265
Working memory Abnormality Present:please specify
Description

Working memory Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0561734
Recent (Episodic) Memory Abnormality Present
Description

Recent (Episodic) Memory

Data type

integer

Alias
UMLS CUI [1]
C0561843
Recent (Episodic) Memory Abnormality Present: please specify
Description

Recent (Episodic) Memory Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0233805
Remote (Semantic) Memory Abnormality Present
Description

Remote (Semantic) Memory

Data type

integer

Alias
UMLS CUI [1]
C0233793
Remote (Semantic) Memory Abnormality Present:please specify
Description

Remote (Semantic) Memory Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0233806
Language Spontaneous speech Abnormality Present
Description

Language Spontaneous speech

Data type

integer

Alias
UMLS CUI [1]
C0855217
Language Spontaneous speech Abnormality Present:please specify
Description

Language Spontaneous speech Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0855217
Language comprehension Abnormality Present
Description

Language comprehension

Data type

integer

Alias
UMLS CUI [1]
C0233733
Language comprehension Abnormality Present:please specify
Description

Language comprehension Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0239083
Naming Abnormality Present
Description

Naming

Data type

integer

Alias
UMLS CUI [1]
C0233735
Naming Abnormality Present:please specify
Description

Naming Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0233736
Repetition Abnormality Present
Description

Repetition

Data type

integer

Alias
UMLS CUI [1]
C0589243
Repetition Abnormality Present:please specify
Description

Repetition Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0233742
Reading Abnormality Present
Description

Reading

Data type

integer

Alias
UMLS CUI [1]
C0586742
Reading Abnormality Present:please specify
Description

Reading Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0586742
Affect Abnormality Present
Description

Affect

Data type

integer

Alias
UMLS CUI [1]
C0001721
Affect Abnormality Present:please specify
Description

Affect Abnormality Present

Data type

text

Alias
UMLS CUI [1]
C0814063
Cranial Nerves
Description

Cranial Nerves

Cranial Nerves global assessment
Description

Cranial Nerves global assessment

Data type

integer

Alias
UMLS CUI [1,1]
C0010268
UMLS CUI [1,2]
C0017644
Cranial Nerves global assessment:please specify
Description

Cranial Nerves global assessment

Data type

text

Alias
UMLS CUI [1,1]
C0010268
UMLS CUI [1,2]
C0017644
CN II Abnormality
Description

CN II Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0029131
CN II Abnormality:please specify
Description

CN II Abnormality

Data type

text

Alias
UMLS CUI [1]
C0029131
CN III Abnormality
Description

CN III Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234270
CN III Abnormality:please specify
Description

CN III Abnormality

Data type

text

Alias
UMLS CUI [1]
C0271353
CN IV Abnormality
Description

CN IV Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234272
CN IV Abnormality:please specify
Description

CN IV Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234271
CN V Abnormality
Description

CN V Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234275
CN V Abnormality:please specify
Description

CN V Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234274
CN VI Abnormality
Description

CN VI Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234287
CN VI Abnormality:please specify
Description

CN VI Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234286
CN VII Abnormality
Description

CN VII Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234290
CN VII Abnormality:please specify
Description

CN VII Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234289
CN VIII Abnormality
Description

CN VIII Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234309
CN VIII Abnormality:please specify
Description

CN VIII Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234308
CN IX Abnormality
Description

CN IX Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234315
CN IX Abnormality:please specify
Description

CN IX Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234314
CN X Abnormality
Description

CN X Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234325
CN X Abnormality:please specify
Description

CN X Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234324
CN XI Abnormality
Description

CN XI Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234335
CN XI Abnormality:please specify
Description

CN XI Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234334
CN XII Abnormality
Description

CN XII Abnormality

Data type

integer

Alias
UMLS CUI [1]
C0234339
CN XII Abnormality:please specify
Description

CN XII Abnormality

Data type

text

Alias
UMLS CUI [1]
C0234338
Nystagmus
Description

Nystagmus

Data type

integer

Alias
UMLS CUI [1]
C0028738
Nystagmus:please specify if cannot be assessed
Description

Nystagmus

Data type

text

Alias
UMLS CUI [1]
C0028738
Type of Nystagmus
Description

Type of Nystagmus

Data type

integer

Alias
UMLS CUI [1]
C0028738
Type of Nystagmus:if other type, please specify
Description

Type of Nystagmus

Data type

text

Alias
UMLS CUI [1]
C0028738
Motor Assessments
Description

Motor Assessments

Muscle Bulk global assessment
Description

If ‘No´ skip to question 8

Data type

integer

Alias
UMLS CUI [1,1]
C0242692
UMLS CUI [1,2]
C0017644
Muscle Bulk global assessment: if cannot be assessed, please specify
Description

Muscle Bulk global assessment

Data type

text

Alias
UMLS CUI [1,1]
C0242692
UMLS CUI [1,2]
C0017644
Muscle Bulk global assessment: if abnormal, please specify type
Description

Muscle Bulk global assessment

Data type

integer

Alias
UMLS CUI [1,1]
C0242692
UMLS CUI [1,2]
C0017644
Right upper extremity Abnormality
Description

Right upper extremity

Data type

integer

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity if abnormal,please specify type
Description

Right upper extremity Abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity Abnormality if cannot be assessed, please specify
Description

Right upper extremity Abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity Abnormality:if other please specify
Description

Right upper extremity Abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Left upper extremity Abnormality
Description

Left upper extremity Abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity Abnormality:if cannot be assessed please specify
Description

Left upper extremity Abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity if abnormal, please specify type
Description

Left upper extremity Abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity Abnormality:if other please specify
Description

Left upper extremity Abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Right lower extremity Abnormality
Description

Right lower extremity Abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity Abnormality:if cannot be assessed please specify
Description

Right lower extremity Abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity if abnormal, please specify type
Description

Right lower extremity Abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity Abnormality:if other,please specify
Description

Right lower extremity Abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Left lower extremity Abnormality
Description

Left lower extremity Abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity Abnormality:if cannot be assessed, please specify
Description

Left lower extremity Abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity if abnormal, please specify type
Description

Left lower extremity Abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity Abnormality: if other,please specify
Description

Left lower extremity Abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Muscle Tone global assessment
Description

If ‘No” skip to question 9

Data type

integer

Alias
UMLS CUI [1,1]
C0026841
UMLS CUI [1,2]
C0017644
Muscle Tone global assessment: if cannot be assessed, please specify
Description

Muscle Tone global assessment

Data type

text

Alias
UMLS CUI [1,1]
C0026841
UMLS CUI [1,2]
C0017644
Muscle Tone global assessment if abnormal, please specify type
Description

Muscle Tone global assessment

Data type

integer

Alias
UMLS CUI [1,1]
C0026841
UMLS CUI [1,2]
C0017644
Right upper extremity muscle tone abnormality
Description

Right upper extremity muscle tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity muscle tone abnormality:if cannot be assessed, please specify
Description

Right upper extremity muscle tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity muscle tone if abnormal, please specify type
Description

Right upper extremity muscle tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity muscle tone abnormality: if other, please specify
Description

Right upper extremity muscle tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Left upper extremity muscle tone abnormality
Description

Left upper extremity muscle tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity muscle tone abnormality:if cannot be assessed, please specify
Description

Left upper extremity muscle tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity muscle tone if abnormal, please specify type
Description

Left upper extremity muscle tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity muscle tone abnormality:if other,please specify
Description

Left upper extremity muscle tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Right lower extremity muscle tone abnormality
Description

Right lower extremity muscle tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity muscle tone abnormality: if cannot be assessed, please specify
Description

Right lower extremity muscle tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity muscle tone if abnormal, please specify type
Description

Right lower extremity muscle tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity muscle tone abnormality:if other, please specify
Description

Right lower extremity muscle tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Left lower extremity muscle tone abnormality
Description

Left lower extremity muscle tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity muscle tone abnormality:if cannot be assessed, please specify
Description

Left lower extremity muscle tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity muscle tone if abnormal, please specify type
Description

Left lower extremity muscle tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity muscle tone abnormality: if other, please specify
Description

Left lower extremity muscle tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Truncal tone abnormality
Description

Truncal tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0026841
UMLS CUI [1,2]
C0460005
UMLS CUI [1,3]
C0031809
Truncal tone abnormality:if cannot be assessed, please specify
Description

Truncal tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0026841
UMLS CUI [1,2]
C0460005
UMLS CUI [1,3]
C0031809
Truncal tone if abnormal, please specify type
Description

Truncal tone abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0026841
UMLS CUI [1,2]
C0460005
UMLS CUI [1,3]
C0031809
Truncal tone abnormality: if other, please specify
Description

Truncal tone abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0026841
UMLS CUI [1,2]
C0460005
UMLS CUI [1,3]
C0031809
Muscle Strength global assessment
Description

If ‘No´skip to question 10

Data type

integer

Alias
UMLS CUI [1,1]
C0517349
UMLS CUI [1,2]
C0017644
Muscle Strength global assessment:if cannot be assessed, please specify
Description

Muscle Strength global assessment

Data type

text

Alias
UMLS CUI [1,1]
C0517349
UMLS CUI [1,2]
C0017644
Muscle Strength global assessment: if abnormal,please specify type
Description

Muscle Strength global assessment

Data type

integer

Alias
UMLS CUI [1,1]
C0517349
UMLS CUI [1,2]
C0017644
Right upper extremity muscle strength abnormality
Description

Right upper extremity muscle strength abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity muscle strength abnormality:if cannot be assessed, please specify
Description

Right upper extremity muscle strength abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity muscle strength if abnormal,please specify type
Description

Right upper extremity muscle strength abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Right upper extremity muscle strength abnormality:if other, please specify
Description

Right upper extremity muscle strength abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230329
UMLS CUI [1,2]
C0031809
Left upper extremity muscle strength abnormality
Description

Left upper extremity muscle strength abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity muscle strength abnormality:if cannot be assessed, please specify
Description

Left upper extremity muscle strength abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity muscle strength if abnormal, please specify type
Description

Left upper extremity muscle strength abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Left upper extremity muscle strength abnormality:if other, please specify
Description

Left upper extremity muscle strength abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0230330
Right lower extremity muscle strength abnormality
Description

Right lower extremity muscle strength abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity muscle strength abnormality:if cannot be assessed, please specify
Description

Right lower extremity muscle strength abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity muscle strength if abnormal, please specify type
Description

Right lower extremity muscle strength abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Right lower extremity muscle strength abnormality:if other,please specify
Description

Right lower extremity muscle strength abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230415
UMLS CUI [1,2]
C0031809
Left lower extremity muscle strength abnormality
Description

Left lower extremity muscle strength abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity muscle strength abnormality:if cannot be assessed, please specify
Description

Left lower extremity muscle strength abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity muscle strength if abnormal, please specify type
Description

Left lower extremity muscle strength abnormality

Data type

integer

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Left lower extremity muscle strength abnormality:if other, please specify
Description

Left lower extremity muscle strength abnormality

Data type

text

Alias
UMLS CUI [1,1]
C0230416
UMLS CUI [1,2]
C0031809
Weakness
Description

If yes, please specify below

Data type

boolean

Alias
UMLS CUI [1]
C0151786
Does the weakness suggest one of the following patterns?
Description

Weakness

Data type

integer

Alias
UMLS CUI [1]
C0151786
Weakness,if applicable please describe further
Description

Weakness

Data type

text

Alias
UMLS CUI [1]
C0151786
Specify the neurological location of the weakness
Description

Weakness

Data type

integer

Alias
UMLS CUI [1]
C0151786
If other neurological location, please specify
Description

Weakness

Data type

text

Alias
UMLS CUI [1]
C0151786
Tremor
Description

If yes,please specify type below

Data type

integer

Alias
UMLS CUI [1]
C0040822
Tremor, if applicable please specify or explain further
Description

Tremor

Data type

text

Alias
UMLS CUI [1]
C0040822
Type of tremor
Description

Tremor

Data type

integer

Alias
UMLS CUI [1]
C0040822
If other type of tremor,please specify
Description

Tremor

Data type

text

Alias
UMLS CUI [1]
C0040822
Cerebellar/Coordination
Description

Cerebellar/Coordination

Finger-to-Nose Abnormality
Description

Cerebellar/Coordination function

Data type

integer

Alias
UMLS CUI [1]
C2228430
Finger-to-nose abnormality:if other, please specify
Description

Cerebellar/Coordination function

Data type

text

Alias
UMLS CUI [1]
C2228430
Finger-to-nose if abnormal please explain
Description

Select all that apply

Data type

integer

Alias
UMLS CUI [1]
C2228430
Finger-to-nose abnormality:if other, please specify
Description

Cerebellar/Coordination function

Data type

text

Alias
UMLS CUI [1]
C2228430
Rapid Alternating Movements abnormality
Description

Cerebellar/Coordination function

Data type

integer

Alias
UMLS CUI [1]
C2228430
Rapid Alternating Movements abnormality: if other,please specify
Description

Cerebellar/Coordination function

Data type

text

Alias
UMLS CUI [1]
C2228430
Rapid Alternating Movements if abnormal, please explain
Description

Select all that apply

Data type

integer

Alias
UMLS CUI [1]
C2228430
Rapid Alternating Movements abnormality: if other,please specify
Description

Cerebellar/Coordination function

Data type

text

Alias
UMLS CUI [1]
C2228430
Heel-to-shin abnormality
Description

Cerebellar/Coordination function

Data type

integer

Alias
UMLS CUI [1]
C2228430
Heel-to-shin abnormality:if other,please specify
Description

Cerebellar/Coordination function

Data type

text

Alias
UMLS CUI [1]
C2228430
Heel-to-shin if abnormal,please explain
Description

Select all that apply

Data type

integer

Alias
UMLS CUI [1]
C2228430
Heel-to-shin abnormality:if other,please specify
Description

Cerebellar/Coordination function

Data type

text

Alias
UMLS CUI [1]
C2228430
Reflexes
Description

Reflexes

Reflexes global assessment
Description

Reflexes global assessment

Data type

integer

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0017644
Reflexes of right arm
Description

Reflexes

Data type

integer

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0230329
Reflexes of left arm
Description

Reflexes

Data type

integer

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0230330
Reflexes of right leg
Description

Reflexes

Data type

integer

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0230415
Reflexes of left leg
Description

Reflexes

Data type

integer

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0230416
Plantar response right
Description

Reflexes

Data type

integer

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0437428
Plantar response left
Description

Reflexes

Data type

integer

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0437428
Plantar response right: if other,please specify
Description

Reflexes

Data type

text

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0437428
Plantar response left: if other,please specify
Description

Reflexes

Data type

text

Alias
UMLS CUI [1,1]
C0436145
UMLS CUI [1,2]
C0437428
Gait
Description

Gait

Gait global assessment
Description

Gait global assessment

Data type

integer

Alias
UMLS CUI [1,1]
C0203969
UMLS CUI [1,2]
C0017644
Gait global assessment,if other please specify
Description

Gait global assessment

Data type

text

Alias
UMLS CUI [1,1]
C0203969
UMLS CUI [1,2]
C0017644
Type of abnormal gait
Description

Gait

Data type

integer

Alias
UMLS CUI [1]
C0203969
If other abnormal type of gait, please specify
Description

Gait

Data type

text

Alias
UMLS CUI [1]
C0203969
Sensory/Sensation
Description

Sensory/Sensation

Sensory System global assessment
Description

Sensory System global assessment

Data type

integer

Alias
UMLS CUI [1,1]
C0682648
UMLS CUI [1,2]
C0017644
Sensory system global assessment symmetry of abnormality
Description

Sensory system global assessment

Data type

integer

Alias
UMLS CUI [1,1]
C0682648
UMLS CUI [1,2]
C0017644
Sensory system location of abnormality
Description

Select all that apply

Data type

integer

Alias
UMLS CUI [1,1]
C0682648
UMLS CUI [1,2]
C0031809
Sensory system location of abnormality: if applicable,please explain/specify further
Description

Sensory system

Data type

text

Alias
UMLS CUI [1,1]
C0682648
UMLS CUI [1,2]
C0031809
Sensory system, patient description of abnormal symptoms
Description

Sensory system patient description

Data type

text

Alias
UMLS CUI [1,1]
C0682648
UMLS CUI [1,2]
C0424450
Sensory modalities affected
Description

Select all that apply

Data type

integer

Alias
UMLS CUI [1,1]
C0682648
UMLS CUI [1,2]
C0031809
If other sensory modality is affected, please specify
Description

Sensory system

Data type

text

Alias
UMLS CUI [1,1]
C0682648
UMLS CUI [1,2]
C0031809
Physical Exam
Description

Physical Exam

Date of examination:
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
If follow-up exam, change from prior exam
Description

Follow up

Data type

integer

Alias
UMLS CUI [1]
C0589120
If other change from prior exam, please specify
Description

Follow up

Data type

text

Alias
UMLS CUI [1]
C0589120
Tanner Stage
Description

Recommended for pediatric studies ONLY

Data type

integer

Alias
UMLS CUI [1]
C2197575
UMLS CUI [2]
C2197573
UMLS CUI [3]
C0429602
UMLS CUI [4]
C0429596
Handedness
Description

Handedness

Data type

integer

Alias
UMLS CUI [1]
C0023114
Constitutional symptoms (e.g., fever, weight loss)
Description

Constitutional symptoms

Data type

integer

Alias
UMLS CUI [1]
C0009812
Eyes
Description

Eyes

Data type

integer

Alias
UMLS CUI [1]
C0015392
Ears, Nose, Mouth, and Throat
Description

Ears, Nose, Mouth, and Throat

Data type

integer

Alias
UMLS CUI [1,1]
C0553490
UMLS CUI [1,2]
C0031809
Cardiovascular
Description

Cardiovascular

Data type

integer

Alias
UMLS CUI [1]
C0007226
Respiratory
Description

Respiratory

Data type

integer

Alias
UMLS CUI [1]
C0035237
Gastrointestinal
Description

Gastrointestinal

Data type

integer

Alias
UMLS CUI [1]
C0012240
Genitourinary
Description

Genitourinary

Data type

integer

Alias
UMLS CUI [1]
C0042066
Musculoskeletal
Description

Musculoskeletal

Data type

integer

Alias
UMLS CUI [1]
C0026860
Integumentary (skin and/or breast)
Description

Integumentary

Data type

integer

Alias
UMLS CUI [1]
C0037267
Neurological
Description

Neurological

Data type

integer

Alias
UMLS CUI [1]
C0027763
Psychiatric
Description

Psychiatric

Data type

integer

Alias
UMLS CUI [1]
C0846574
Endocrine system
Description

Endocrine

Data type

integer

Alias
UMLS CUI [1]
C0014136
Hematologic/Lymphatic
Description

Hematologic/Lymphatic

Data type

integer

Alias
UMLS CUI [1]
C1442298
Allergic/Immunologic
Description

Allergic/Immunologic

Data type

integer

Alias
UMLS CUI [1,1]
C0021053
UMLS CUI [1,2]
C0020517
Constitutional symptoms (e.g., fever, weight loss): Please specify any abnormality or if not examined
Description

Constitutional symptoms

Data type

text

Alias
UMLS CUI [1]
C0009812
Eyes: please specify any abnormality or if not examined
Description

Eyes

Data type

text

Alias
UMLS CUI [1]
C0015392
Ears, Nose, Mouth, and Throat: please specify any abnormality or if not examined
Description

Ears, Nose, Mouth, and Throat

Data type

text

Alias
UMLS CUI [1,1]
C0553490
UMLS CUI [1,2]
C0031809
Cardiovascular:Please specify any abnormality or if not examined
Description

Cardiovascular

Data type

text

Alias
UMLS CUI [1]
C0007226
Respiratory:Please specify any abnormality or if not examined
Description

Respiratory

Data type

text

Alias
UMLS CUI [1]
C0035237
Gastrointestinal: please specify any abnormality or if not examined
Description

Gastrointestinal

Data type

text

Alias
UMLS CUI [1]
C0012240
Genitourinary:please specify any abnormality or if not examined
Description

Genitourinary

Data type

text

Alias
UMLS CUI [1]
C0042066
Musculoskeletal: Please specify any abnormality or if not examined
Description

Musculoskeletal

Data type

text

Alias
UMLS CUI [1]
C0026860
Integumentary (skin and/or breast):Please specify any abnormality or if not examined
Description

Integumentary

Data type

text

Alias
UMLS CUI [1]
C0037267
Neurological: Please specify any abnormality or if not examined
Description

Neurological

Data type

text

Alias
UMLS CUI [1]
C0027763
Psychiatric:Please specify any abnormality or if not examined
Description

Psychiatric

Data type

text

Alias
UMLS CUI [1]
C0846574
Endocrine system: please specify any abnormality or if not examined
Description

Endocrine

Data type

text

Alias
UMLS CUI [1]
C0014136
Hematologic/Lymphatic:Please specify any abnormality or if not examined
Description

Hematologic/Lymphatic

Data type

text

Alias
UMLS CUI [1]
C1442298
Allergic/Immunologic: please specify abnormality or if not examined
Description

Allergic/Immunologic

Data type

text

Alias
UMLS CUI [1,1]
C0021053
UMLS CUI [1,2]
C0020517
Vital Signs
Description

Vital Signs

Date of exam
Description

mm/dd/yyyy

Data type

date

Alias
UMLS CUI [1]
C0011008
Time
Description

Time

Data type

integer

Alias
UMLS CUI [1]
C0040223
Heart rate
Description

Heart rate

Data type

integer

Measurement units
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
Respiratory Rate
Description

Respiratory Rate

Data type

integer

Measurement units
  • breath/min
Alias
UMLS CUI [1]
C0231832
breath/min
Blood pressure measurement (syst/dia)
Description

Blood pressure

Data type

integer

Measurement units
  • mm/Hg
Alias
UMLS CUI [1]
C0005823
mm/Hg
Participants position during blood pressure measurement
Description

Position

Data type

integer

Alias
UMLS CUI [1]
C0733755
Temperature
Description

Temperature

Data type

float

Alias
UMLS CUI [1]
C0039476
Unit for temperature measurement
Description

Temperature

Data type

integer

Alias
UMLS CUI [1]
C0039476
Method of temperature measurement
Description

Temperature

Data type

integer

Alias
UMLS CUI [1]
C0039476
If other method of measurement, please specify
Description

Temperature

Data type

text

Alias
UMLS CUI [1]
C0039476
Body weight
Description

Weight

Data type

float

Alias
UMLS CUI [1]
C0005910
Unit for body weight
Description

Body weight

Data type

integer

Alias
UMLS CUI [1]
C0005910
Body Height
Description

Body Height

Data type

float

Alias
UMLS CUI [1]
C0005890
Unit for body height
Description

Body height

Data type

integer

Alias
UMLS CUI [1]
C0005890
Head circumference
Description

This element is recommended for pediatric studies

Data type

float

Alias
UMLS CUI [1]
C0262499
Unit for Head circumference
Description

Head circumference

Data type

integer

Alias
UMLS CUI [1]
C0262499
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Similar models

Assessments and Examinations

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Neurological examination
Study ID
Item
Study ID
text
C2826693 (UMLS CUI [1])
Study site
Item
Study site name
text
C2825164 (UMLS CUI [1])
Subject ID
Item
Subject ID
text
C2348585 (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])
Follow up
Code List
If follow-up exam, change from prior exam
CL Item
No change (1)
CL Item
Improved (2)
CL Item
Worse (3)
CL Item
Unknown (4)
CL Item
Other, specify (5)
Follow up
Item
If other change from prior exam, please specify
text
C0589120 (UMLS CUI [1])
Item Group
Mental Status
Item
Mental assessments:Attention Abnormality Present
text
C1444362 (UMLS CUI [1])
Mental assessment
Code List
Mental assessments:Attention Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
Attention Abnormality Present
Item
Attention Abnormality Present: please specify
text
C0238707 (UMLS CUI [1])
Item
Working memory Abnormality Present
integer
C0025265 (UMLS CUI [1])
Mental assessment
Code List
Working memory Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
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])
Mental assessment
Code List
Recent (Episodic) Memory Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
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])
Mental assessment
Code List
Remote (Semantic) Memory Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
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])
Mental assessment
Code List
Language Spontaneous speech Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
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])
Mental assessment
Code List
Language comprehension Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
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])
Mental assessment
Code List
Naming Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
Naming Abnormality Present
Item
Naming Abnormality Present:please specify
text
C0233736 (UMLS CUI [1])
Item
Repetition Abnormality Present
integer
C0589243 (UMLS CUI [1])
Mental assessment
Code List
Repetition Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
Repetition Abnormality Present
Item
Repetition Abnormality Present:please specify
text
C0233742 (UMLS CUI [1])
Item
Reading Abnormality Present
integer
C0586742 (UMLS CUI [1])
Mental assessment
Code List
Reading Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
Reading Abnormality Present
Item
Reading Abnormality Present:please specify
text
C0586742 (UMLS CUI [1])
Item
Affect Abnormality Present
integer
C0001721 (UMLS CUI [1])
Mental assessment
Code List
Affect Abnormality Present
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Unknown (3)
Affect Abnormality Present
Item
Affect Abnormality Present:please specify
text
C0814063 (UMLS CUI [1])
Item Group
Cranial Nerves
Item
Cranial Nerves global assessment
integer
C0010268 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Cranial Nerves global assessment
Code List
Cranial Nerves global assessment
CL Item
Normal (1)
CL Item
Abnormal (explain further in questions 5a through 5k below) (2)
CL Item
Cannot Assess, explain (3)
CL Item
Other, specify (4)
Cranial Nerves global assessment
Item
Cranial Nerves global assessment:please specify
text
C0010268 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Item
CN II Abnormality
integer
C0029131 (UMLS CUI [1])
CN II Abnormality
Code List
CN II Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN II Abnormality
Item
CN II Abnormality:please specify
text
C0029131 (UMLS CUI [1])
Item
CN III Abnormality
integer
C0234270 (UMLS CUI [1])
CN II Abnormality
Code List
CN III Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN III Abnormality
Item
CN III Abnormality:please specify
text
C0271353 (UMLS CUI [1])
Item
CN IV Abnormality
integer
C0234272 (UMLS CUI [1])
CN II Abnormality
Code List
CN IV Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN IV Abnormality
Item
CN IV Abnormality:please specify
text
C0234271 (UMLS CUI [1])
Item
CN V Abnormality
integer
C0234275 (UMLS CUI [1])
CN II Abnormality
Code List
CN V Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN V Abnormality
Item
CN V Abnormality:please specify
text
C0234274 (UMLS CUI [1])
Item
CN VI Abnormality
integer
C0234287 (UMLS CUI [1])
CN II Abnormality
Code List
CN VI Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN VI Abnormality
Item
CN VI Abnormality:please specify
text
C0234286 (UMLS CUI [1])
Item
CN VII Abnormality
integer
C0234290 (UMLS CUI [1])
CN II Abnormality
Code List
CN VII Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN VII Abnormality
Item
CN VII Abnormality:please specify
text
C0234289 (UMLS CUI [1])
Item
CN VIII Abnormality
integer
C0234309 (UMLS CUI [1])
CN II Abnormality
Code List
CN VIII Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN VIII Abnormality
Item
CN VIII Abnormality:please specify
text
C0234308 (UMLS CUI [1])
Item
CN IX Abnormality
integer
C0234315 (UMLS CUI [1])
CN II Abnormality
Code List
CN IX Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN IX Abnormality
Item
CN IX Abnormality:please specify
text
C0234314 (UMLS CUI [1])
Item
CN X Abnormality
integer
C0234325 (UMLS CUI [1])
CN II Abnormality
Code List
CN X Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN X Abnormality
Item
CN X Abnormality:please specify
text
C0234324 (UMLS CUI [1])
Item
CN XI Abnormality
integer
C0234335 (UMLS CUI [1])
CN II Abnormality
Code List
CN XI Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN XI Abnormality
Item
CN XI Abnormality:please specify
text
C0234334 (UMLS CUI [1])
Item
CN XII Abnormality
integer
C0234339 (UMLS CUI [1])
CN II Abnormality
Code List
CN XII Abnormality
CL Item
Left  (1)
CL Item
Right  (2)
CL Item
Bilateral (3)
CN XII Abnormality
Item
CN XII Abnormality:please specify
text
C0234338 (UMLS CUI [1])
Item
Nystagmus
integer
C0028738 (UMLS CUI [1])
Nystagmus
Code List
Nystagmus
CL Item
Yes (Specify type below)  (1)
CL Item
No  (2)
CL Item
Cannot Assess, explain (3)
Nystagmus
Item
Nystagmus:please specify if cannot be assessed
text
C0028738 (UMLS CUI [1])
Item
Type of Nystagmus
integer
C0028738 (UMLS CUI [1])
Type of Nystagmus
Code List
Type of Nystagmus
CL Item
Physiologic  (1)
CL Item
Abnormal  (2)
CL Item
Other, specify (3)
Type of Nystagmus
Item
Type of Nystagmus:if other type, please specify
text
C0028738 (UMLS CUI [1])
Item Group
Motor Assessments
Item
Muscle Bulk global assessment
integer
C0242692 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Left lower extremity Abnormality
Code List
Muscle Bulk global assessment
CL Item
Yes  (1)
CL Item
No (2)
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])
Muscle Bulk global assessment
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])
Left lower extremity Abnormality
Code List
Right upper extremity Abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity Abnormality
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])
Left lower extremity Abnormality
Code List
Left upper extremity Abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity Abnormality
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])
Left lower extremity Abnormality
Code List
Right lower extremity Abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity Abnormality
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])
Left lower extremity Abnormality
Code List
Left lower extremity Abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity Abnormality
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])
Left lower extremity Abnormality
Code List
Muscle Tone global assessment
CL Item
Yes  (1)
CL Item
No (2)
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])
Muscle Bulk global assessment
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])
Left lower extremity Abnormality
Code List
Right upper extremity muscle tone abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity muscle tone abnormality
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])
Left lower extremity Abnormality
Code List
Left upper extremity muscle tone abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity muscle tone abnormality
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])
Left lower extremity Abnormality
Code List
Right lower extremity muscle tone abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity muscle tone abnormality
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])
Left lower extremity Abnormality
Code List
Left lower extremity muscle tone abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity muscle tone abnormality
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])
Left lower extremity Abnormality
Code List
Truncal tone abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Truncal tone abnormality
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])
Left lower extremity Abnormality
Code List
Muscle Strength global assessment
CL Item
Yes  (1)
CL Item
No (2)
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])
Muscle Bulk global assessment
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])
Left lower extremity Abnormality
Code List
Right upper extremity muscle strength abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity Abnormality
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])
Left lower extremity Abnormality
Code List
Left upper extremity muscle strength abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity Abnormality
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])
Left lower extremity Abnormality
Code List
Right lower extremity muscle strength abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity Abnormality
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])
Left lower extremity Abnormality
Code List
Left lower extremity muscle strength abnormality
CL Item
Yes  (1)
CL Item
No (2)
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])
Right upper extremity Abnormality
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])
Weakness
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])
Weakness
Code List
Specify the neurological location of the weakness
CL Item
Brain (1)
CL Item
Spinal Cord (2)
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])
Tremor
Code List
Tremor
CL Item
Yes (1)
CL Item
No  (2)
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])
Tremor
Code List
Type of tremor
CL Item
Postural (1)
CL Item
Rest (2)
CL Item
Intention (3)
CL Item
Other, specify (4)
CL Item
 (5)
CL Item
  (6)
Tremor
Item
If other type of tremor,please specify
text
C0040822 (UMLS CUI [1])
Item Group
Cerebellar/Coordination
Item
Finger-to-Nose Abnormality
integer
C2228430 (UMLS CUI [1])
Cerebellar/Coordination function
Code List
Finger-to-Nose Abnormality
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Cannot Assess (3)
CL Item
Other specify (4)
Cerebellar/Coordination function
Item
Finger-to-nose abnormality:if other, please specify
text
C2228430 (UMLS CUI [1])
Item
Finger-to-nose if abnormal please explain
integer
C2228430 (UMLS CUI [1])
Cerebellar/Coordination function
Code List
Finger-to-nose if abnormal please explain
CL Item
RUE  (1)
CL Item
LUE (2)
CL Item
Dysmetria  (3)
CL Item
Slowness (4)
CL Item
Cannot Assess due to Weakness (5)
CL Item
Other, specify (6)
Cerebellar/Coordination function
Item
Finger-to-nose abnormality:if other, please specify
text
C2228430 (UMLS CUI [1])
Item
Rapid Alternating Movements abnormality
integer
C2228430 (UMLS CUI [1])
Cerebellar/Coordination function
Code List
Rapid Alternating Movements abnormality
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Cannot Assess (3)
CL Item
Other specify (4)
Cerebellar/Coordination function
Item
Rapid Alternating Movements abnormality: if other,please specify
text
C2228430 (UMLS CUI [1])
Item
Rapid Alternating Movements if abnormal, please explain
integer
C2228430 (UMLS CUI [1])
Cerebellar/Coordination function
Code List
Rapid Alternating Movements if abnormal, please explain
CL Item
RUE  (1)
CL Item
LUE (2)
CL Item
Dysmetria  (3)
CL Item
Slowness (4)
CL Item
Cannot Assess due to Weakness (5)
CL Item
Other, specify (6)
Cerebellar/Coordination function
Item
Rapid Alternating Movements abnormality: if other,please specify
text
C2228430 (UMLS CUI [1])
Item
Heel-to-shin abnormality
integer
C2228430 (UMLS CUI [1])
Cerebellar/Coordination function
Code List
Heel-to-shin abnormality
CL Item
Yes  (1)
CL Item
No (2)
CL Item
Cannot Assess (3)
CL Item
Other specify (4)
Cerebellar/Coordination function
Item
Heel-to-shin abnormality:if other,please specify
text
C2228430 (UMLS CUI [1])
Item
Heel-to-shin if abnormal,please explain
integer
C2228430 (UMLS CUI [1])
Cerebellar/Coordination function
Code List
Heel-to-shin if abnormal,please explain
CL Item
RUE  (1)
CL Item
LUE (2)
CL Item
Dysmetria  (3)
CL Item
Slowness (4)
CL Item
Cannot Assess due to Weakness (5)
CL Item
Other, specify (6)
Cerebellar/Coordination function
Item
Heel-to-shin abnormality:if other,please specify
text
C2228430 (UMLS CUI [1])
Item Group
Reflexes
Item
Reflexes global assessment
integer
C0436145 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Reflexes global assessment
Code List
Reflexes global assessment
CL Item
Normal (1)
CL Item
Abnormal (specify below) (2)
CL Item
Cannot Assess (3)
CL Item
Other, specify (4)
Item
Reflexes of right arm
integer
C0436145 (UMLS CUI [1,1])
C0230329 (UMLS CUI [1,2])
Reflexes
Code List
Reflexes of right arm
CL Item
Increased with clonus (1)
CL Item
Increased without clonus (2)
CL Item
Hypoactive (3)
CL Item
Absent (4)
Item
Reflexes of left arm
integer
C0436145 (UMLS CUI [1,1])
C0230330 (UMLS CUI [1,2])
Reflexes
Code List
Reflexes of left arm
CL Item
Increased with clonus (1)
CL Item
Increased without clonus (2)
CL Item
Hypoactive (3)
CL Item
Absent (4)
Item
Reflexes of right leg
integer
C0436145 (UMLS CUI [1,1])
C0230415 (UMLS CUI [1,2])
Reflexes
Code List
Reflexes of right leg
CL Item
Increased with clonus (1)
CL Item
Increased without clonus (2)
CL Item
Hypoactive (3)
CL Item
Absent (4)
Item
Reflexes of left leg
integer
C0436145 (UMLS CUI [1,1])
C0230416 (UMLS CUI [1,2])
Reflexes
Code List
Reflexes of left leg
CL Item
Increased with clonus (1)
CL Item
Increased without clonus (2)
CL Item
Hypoactive (3)
CL Item
Absent (4)
Item
Plantar response right
integer
C0436145 (UMLS CUI [1,1])
C0437428 (UMLS CUI [1,2])
Reflexes
Code List
Plantar response right
CL Item
Flexor (1)
CL Item
Extensor (2)
CL Item
Equivocal (3)
CL Item
Cannot Assess (4)
CL Item
Other, specify (5)
Item
Plantar response left
integer
C0436145 (UMLS CUI [1,1])
C0437428 (UMLS CUI [1,2])
Reflexes
Code List
Plantar response left
CL Item
Flexor (1)
CL Item
Extensor (2)
CL Item
Equivocal (3)
CL Item
Cannot Assess (4)
CL Item
Other, specify (5)
Reflexes
Item
Plantar response right: if other,please specify
text
C0436145 (UMLS CUI [1,1])
C0437428 (UMLS CUI [1,2])
Reflexes
Item
Plantar response left: if other,please specify
text
C0436145 (UMLS CUI [1,1])
C0437428 (UMLS CUI [1,2])
Item Group
Gait
Item
Gait global assessment
integer
C0203969 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Gait global assessment
Code List
Gait global assessment
CL Item
Normal  (1)
CL Item
Abnormal (Indicate type below)  (2)
CL Item
Cannot Assess  (3)
CL Item
Other, specify (4)
Gait global assessment
Item
Gait global assessment,if other please specify
text
C0203969 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Item
Type of abnormal gait
integer
C0203969 (UMLS CUI [1])
Gait
Code List
Type of abnormal gait
CL Item
Ataxic Gait (1)
CL Item
Hemiparetic Gait–Left side (2)
CL Item
Hemiparetic Gait–Right side (3)
CL Item
Diplegic Gait (4)
CL Item
Parkinsonian Gait (5)
CL Item
Other Gait Abnormalities, specify (6)
Gait
Item
If other abnormal type of gait, please specify
text
C0203969 (UMLS CUI [1])
Item Group
Sensory/Sensation
Item
Sensory System global assessment
integer
C0682648 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Reflexes global assessment
Code List
Sensory System global assessment
CL Item
Normal (1)
CL Item
Abnormal (specify below) (2)
CL Item
Cannot Assess (3)
CL Item
Other, specify (4)
Item
Sensory system global assessment symmetry of abnormality
integer
C0682648 (UMLS CUI [1,1])
C0017644 (UMLS CUI [1,2])
Sensory system global assessment
Code List
Sensory system global assessment symmetry of abnormality
CL Item
Symmetric  (1)
CL Item
Asymmetric (2)
Item
Sensory system location of abnormality
integer
C0682648 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Sensory system
Code List
Sensory system location of abnormality
CL Item
Stocking, explain (1)
CL Item
Stocking/Glove, explain (2)
CL Item
Dermatome, explain (3)
CL Item
Sensory Nerve, explain (4)
CL Item
Other, specify (5)
Sensory system
Item
Sensory system location of abnormality: if applicable,please explain/specify further
text
C0682648 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Sensory system patient description
Item
Sensory system, patient description of abnormal symptoms
text
C0682648 (UMLS CUI [1,1])
C0424450 (UMLS CUI [1,2])
Item
Sensory modalities affected
integer
C0682648 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Sensory system
Code List
Sensory modalities affected
CL Item
Light Touch (1)
CL Item
Pain and Temperature (2)
CL Item
Vibration (3)
CL Item
Proprioception (4)
CL Item
Other, specify (5)
Sensory system
Item
If other sensory modality is affected, please specify
text
C0682648 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item Group
Physical Exam
Date
Item
Date of examination:
date
C0011008 (UMLS CUI [1])
Item
If follow-up exam, change from prior exam
integer
C0589120 (UMLS CUI [1])
Follow up
Code List
If follow-up exam, change from prior exam
CL Item
No change (1)
CL Item
Improved (2)
CL Item
Worse (3)
CL Item
Unknown (4)
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])
Tanner Stage
Code List
Tanner Stage
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
V (5)
Item
Handedness
integer
C0023114 (UMLS CUI [1])
Handedness
Code List
Handedness
CL Item
Left hand (1)
CL Item
Right hand (2)
CL Item
Both (3)
CL Item
Unknown (4)
Item
Constitutional symptoms (e.g., fever, weight loss)
integer
C0009812 (UMLS CUI [1])
Constitutional symptoms
Code List
Constitutional symptoms (e.g., fever, weight loss)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Eyes
integer
C0015392 (UMLS CUI [1])
Eyes
Code List
Eyes
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Ears, Nose, Mouth, and Throat
integer
C0553490 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Ears, Nose, Mouth, and Throat
Code List
Ears, Nose, Mouth, and Throat
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Cardiovascular
integer
C0007226 (UMLS CUI [1])
Cardiovascular
Code List
Cardiovascular
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Respiratory
integer
C0035237 (UMLS CUI [1])
Respiratory
Code List
Respiratory
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Gastrointestinal
integer
C0012240 (UMLS CUI [1])
Gastrointestinal
Code List
Gastrointestinal
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Genitourinary
integer
C0042066 (UMLS CUI [1])
Genitourinary
Code List
Genitourinary
CL Item
Normal- (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Musculoskeletal
integer
C0026860 (UMLS CUI [1])
Musculoskeletal
Code List
Musculoskeletal
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Integumentary (skin and/or breast)
integer
C0037267 (UMLS CUI [1])
Integumentary
Code List
Integumentary (skin and/or breast)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Neurological
integer
C0027763 (UMLS CUI [1])
Neurological
Code List
Neurological
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Psychiatric
integer
C0846574 (UMLS CUI [1])
Psychiatric
Code List
Psychiatric
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Endocrine system
integer
C0014136 (UMLS CUI [1])
Endocrine
Code List
Endocrine system
CL Item
Normal  (1)
CL Item
Abnormal  (2)
CL Item
Not examined (3)
Item
Hematologic/Lymphatic
integer
C1442298 (UMLS CUI [1])
Hematologic/Lymphatic
Code List
Hematologic/Lymphatic
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Item
Allergic/Immunologic
integer
C0021053 (UMLS CUI [1,1])
C0020517 (UMLS CUI [1,2])
Allergic/Immunologic
Code List
Allergic/Immunologic
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
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])
Item Group
Vital Signs
Date
Item
Date of exam
date
C0011008 (UMLS CUI [1])
Item
Time
integer
C0040223 (UMLS CUI [1])
Time
Code List
Time
CL Item
am (1)
CL Item
pm (2)
CL Item
24-hour clock (3)
Heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Respiratory Rate
Item
Respiratory Rate
integer
C0231832 (UMLS CUI [1])
Blood pressure
Item
Blood pressure measurement (syst/dia)
integer
C0005823 (UMLS CUI [1])
Item
Participants position during blood pressure measurement
integer
C0733755 (UMLS CUI [1])
Position
Code List
Participants position during blood pressure measurement
CL Item
Sitting (1)
CL Item
Standing (2)
CL Item
Supine (3)
Temperature
Item
Temperature
float
C0039476 (UMLS CUI [1])
Item
Unit for temperature measurement
integer
C0039476 (UMLS CUI [1])
Temperature
Code List
Unit for temperature measurement
CL Item
°F (1)
CL Item
°C (2)
Item
Method of temperature measurement
integer
C0039476 (UMLS CUI [1])
Temperature
Code List
Method of temperature measurement
CL Item
Oral (1)
CL Item
Rectal (2)
CL Item
Axillary (3)
CL Item
Tympanic  (4)
CL Item
Bladder (5)
CL Item
Esophageal (6)
CL Item
Brain (7)
CL Item
Other, specify (8)
Temperature
Item
If other method of measurement, please specify
text
C0039476 (UMLS CUI [1])
Weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
Item
Unit for body weight
integer
C0005910 (UMLS CUI [1])
Body weight
Code List
Unit for body weight
CL Item
pounds (1)
CL Item
kilograms (2)
Body Height
Item
Body Height
float
C0005890 (UMLS CUI [1])
Item
Unit for body height
integer
C0005890 (UMLS CUI [1])
Body height
Code List
Unit for body height
CL Item
inches (1)
CL Item
centimeters (2)
Head circumference
Item
Head circumference
float
C0262499 (UMLS CUI [1])
Item
Unit for Head circumference
integer
C0262499 (UMLS CUI [1])
Body height
Code List
Unit for Head circumference
CL Item
inches (1)
CL Item
centimeters (2)
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