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First Doctor's Visit Form

1 forms  
Patient ID
Description

Patient ID

Alias
UMLS CUI-1
C1269815
Indicate the patient's medical record number
Description

This number will not be shared with ICHOM. In the case patient-level data is submitted to ICHOM for benchmarking or research purposes, a separate ICHOM Patient Identifier will be created and cross-linking between the ICHOM Patient Identifier and the medical record number will only be known at the treating institution INCLUSION CRITERIA: All patients TIMING: On all forms REPORTING SOURCE: Administrative or clinical RESPONSE OPTIONS: According to institution

Data type

integer

Alias
UMLS CUI [1]
C1269815
Demographic factors
Description

Demographic factors

Alias
UMLS CUI-1
C1704791
What is your date of birth?
Description

INCLUSION CRITERIA: All patients TIMING: First doctor‘s visit REPORTING SOURCE: Clinical or patient-reported TYPE: Date by DD/MM/YYYY

Data type

date

Measurement units
  • DD/MM/YYYY
Alias
UMLS CUI [1]
C0001779
UMLS CUI [2]
C0421451
DD/MM/YYYY
Please indicate your sex at birth
Description

INCLUSION CRITERIA: All patients TIMING: First doctor‘s visit REPORTING SOURCE: Clinical or patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1]
C0079399
Baseline clinical status
Description

Baseline clinical status

Alias
UMLS CUI-1
C0449440
UMLS CUI-2
C1442488
Did your doctor ever diagnose you with depression prior to your Parkinson's Disease diagnosis?
Description

INCLUSION CRITERIA: All patients TIMING: First doctor‘s visit REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1,1]
C0011581
UMLS CUI [1,2]
C0332152
UMLS CUI [1,3]
C0030567
Did your doctor ever diagnose you with anxiety prior to your Parkinson’s Disease diagnosis?
Description

INCLUSION CRITERIA: All patients TIMING: First doctor‘s visit REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1,1]
C0003467
UMLS CUI [1,2]
C0332152
UMLS CUI [1,3]
C0030567
Before you were diagnosed with Parkinson’s Disease, had you ever been told, or suspected yourself, that you seem to “act out your dreams” while asleep (for example, punching, flailing your arms in the air, making running movements etc.)?
Description

INCLUSION CRITERIA: All patients TIMING: First doctor‘s visit REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1,1]
C0751772
UMLS CUI [1,2]
C0332152
UMLS CUI [1,3]
C0030567
At what age was your Parkinson’s Disease diagnosed?
Description

INCLUSION CRITERIA: All patients TIMING: First doctor‘s visit REPORTING SOURCE: Patient-reported TYPE: Numerical RESPONSE OPTIONS: Numerical value of age in years

Data type

integer

Measurement units
  • a
Alias
UMLS CUI [1,1]
C1828181
UMLS CUI [1,2]
C0030567
a
At what age did your Parkinson’s Disease motor symptoms (e.g., rigidity, tremor, slowness of movement) start?
Description

INCLUSION CRITERIA: All patients TIMING: First doctor‘s visit REPORTING SOURCE: Patient-reported TYPE: Numerical RESPONSE OPTIONS: Numerical value of age in years

Data type

integer

Measurement units
  • a
Alias
UMLS CUI [1,1]
C0150907
UMLS CUI [1,2]
C0030567
a
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Similar models

First Doctor's Visit Form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient ID
C1269815 (UMLS CUI-1)
Patient ID
Item
Indicate the patient's medical record number
integer
C1269815 (UMLS CUI [1])
Item Group
Demographic factors
C1704791 (UMLS CUI-1)
Age
Item
What is your date of birth?
date
C0001779 (UMLS CUI [1])
C0421451 (UMLS CUI [2])
Item
Please indicate your sex at birth
integer
C0079399 (UMLS CUI [1])
Sex
Code List
Please indicate your sex at birth
CL Item
Male (1)
C0086582 (UMLS CUI-1)
(Comment:en)
CL Item
Female (2)
C0086287 (UMLS CUI-1)
(Comment:en)
CL Item
Undisclosed (999)
C0439673 (UMLS CUI-1)
(Comment:en)
Item Group
Baseline clinical status
C0449440 (UMLS CUI-1)
C1442488 (UMLS CUI-2)
Item
Did your doctor ever diagnose you with depression prior to your Parkinson's Disease diagnosis?
integer
C0011581 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0030567 (UMLS CUI [1,3])
Depression before PD diagnosis
Code List
Did your doctor ever diagnose you with depression prior to your Parkinson's Disease diagnosis?
CL Item
No (0)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Yes (1)
C1705108 (UMLS CUI-1)
(Comment:en)
Item
Did your doctor ever diagnose you with anxiety prior to your Parkinson’s Disease diagnosis?
integer
C0003467 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0030567 (UMLS CUI [1,3])
Depression before PD diagnosis
Code List
Did your doctor ever diagnose you with anxiety prior to your Parkinson’s Disease diagnosis?
CL Item
No (0)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Yes (1)
C1705108 (UMLS CUI-1)
(Comment:en)
Item
Before you were diagnosed with Parkinson’s Disease, had you ever been told, or suspected yourself, that you seem to “act out your dreams” while asleep (for example, punching, flailing your arms in the air, making running movements etc.)?
integer
C0751772 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0030567 (UMLS CUI [1,3])
Depression before PD diagnosis
Code List
Before you were diagnosed with Parkinson’s Disease, had you ever been told, or suspected yourself, that you seem to “act out your dreams” while asleep (for example, punching, flailing your arms in the air, making running movements etc.)?
CL Item
No (0)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Yes (1)
C1705108 (UMLS CUI-1)
(Comment:en)
Age at PD diagnosis
Item
At what age was your Parkinson’s Disease diagnosed?
integer
C1828181 (UMLS CUI [1,1])
C0030567 (UMLS CUI [1,2])
Age at PD onset
Item
At what age did your Parkinson’s Disease motor symptoms (e.g., rigidity, tremor, slowness of movement) start?
integer
C0150907 (UMLS CUI [1,1])
C0030567 (UMLS CUI [1,2])
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