ID

34509

Description

This form is used for routine documentation. It originates from a medical practice for internal medicine in Cologne-Lindenthal (medical practice Astrid Schareina and Dr. Christina Lind-Weiland, Lindenthalgürtel 36, 50935 Cologne). Published with permission by A. Schareina and Dr. C. Lind-Weiland. Explanation for patients: Your symptoms (or those of your child) may be allergic, i.e. they may be due to certain substances in your environment (or that of your child). To find the allergy triggers, please answer the following questions. Ihre Beschwerden (oder die Ihres Kindes) können allergischen Ursprungs sein, d. h. sie können auf bestimmte Stoffe in Ihrer Umgebung (oder der Ihres Kindes) zurückzuführen sein. Um die Allergieauslöser zu finden, beantworten Sie bitte folgende Fragen:

Keywords

Versions (1)
  1. 1/18/19 1/18/19 -
Copyright Holder

A. Schareina, Dr. C. Lind-Weiland

Uploaded on

January 18, 2019

DOI

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License

Creative Commons BY-NC 3.0
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Allergy Medical History

German English

Allergy Medical History (Allergieanamnese)

1 forms  
Administrative data
Description

Administrative data

Alias
UMLS CUI-1
C1320722
Surname
Description

Surname

Data type

text

Alias
UMLS CUI [1]
C0421448
First name
Description

First name

Data type

text

Alias
UMLS CUI [1]
C1443235
Health insurance
Description

Health insurance

Data type

text

Alias
UMLS CUI [1]
C0021682
Adress
Description

Adress

Data type

text

Alias
UMLS CUI [1]
C0421449
Telephone number
Description

Telephone number

Data type

integer

Alias
UMLS CUI [1]
C1515258
Mobile phone number
Description

Mobile phone number

Data type

integer

Alias
UMLS CUI [1]
C3273868
E-Mail adress
Description

E-Mail adress

Data type

text

Alias
UMLS CUI [1]
C1705961
Date
Description

Date of visit

Data type

date

Alias
UMLS CUI [1]
C1320303
Occupation
Description

Occupation

Data type

text

Alias
UMLS CUI [1]
C0421456
General practitioner name
Description

General practitioner name

Data type

text

Alias
UMLS CUI [1,1]
C0017319
UMLS CUI [1,2]
C0027365
General practitioner adress
Description

Indication of town name is sufficient.

Data type

text

Alias
UMLS CUI [1,1]
C0017319
UMLS CUI [1,2]
C1442065
Current complaints
Description

Current complaints

Alias
UMLS CUI-1
C0871764
UMLS CUI-2
C0521116
Symptom
Description

Please select each symptom with each corresponding temporal occurence.

Data type

integer

Alias
UMLS CUI [1]
C1457887
Temporal occurrence
Description

Please select each symptom with each corresponding temporal occurence.

Data type

integer

Alias
UMLS CUI [1,1]
C2745955
UMLS CUI [1,2]
C0040223
Medical History
Description

Medical History

Alias
UMLS CUI-1
C0262926
Do the complaints occur in the morning?
Description

Do the complaints occur in the morning?

Data type

boolean

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C2745955
UMLS CUI [1,3]
C0332170
Do the complaints occur during daytime?
Description

Do the complaints occur during daytime?

Data type

boolean

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C2745955
UMLS CUI [1,3]
C0332169
Do the complaints occur at night?
Description

Do the complaints occur at night?

Data type

boolean

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C2745955
UMLS CUI [1,3]
C0240526
Are the complaints increasing in certain places?
Description

If YES, specify below.

Data type

boolean

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C0442808
UMLS CUI [1,3]
C0014406
Specify, in which places complaints are increasing
Description

Specify, in which places complaints are increasing

Data type

text

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C0442808
UMLS CUI [1,3]
C0014406
UMLS CUI [1,4]
C1521902
Do you experience complaints when in contact with animals?
Description

If YES, specify below.

Data type

boolean

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C0332158
UMLS CUI [1,3]
C0003062
Specify: in contact with which animals do complaints occur?
Description

Specify: in contact with which animals do complaints occur?

Data type

text

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C0332158
UMLS CUI [1,3]
C0003062
UMLS CUI [1,4]
C1521902
Have food intolerances been observed or known?
Description

If YES, specify below.

Data type

boolean

Alias
UMLS CUI [1,1]
C0020517
UMLS CUI [1,2]
C0016452
Specify, which food intolerances have been observed or known.
Description

Specify, which food intolerances have been observed or known.

Data type

text

Alias
UMLS CUI [1,1]
C0020517
UMLS CUI [1,2]
C0016452
UMLS CUI [1,3]
C1521902
Do complaints arise during certain activities (e.g. sports, dusting)?
Description

If YES, specify below.

Data type

boolean

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C0026606
UMLS CUI [2]
C0038039
UMLS CUI [3]
C0563970
Specify, during which activity complaints arise.
Description

Specify, during which activity complaints arise.

Data type

text

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C0026606
UMLS CUI [1,3]
C1521902
Were there any increased swellings/rednesses/ persistent itching or other reactions to insect bites? (mosquito, bee, wasp etc.)
Description

If YES, specify below.

Data type

boolean

Alias
UMLS CUI [1,1]
C0021564
UMLS CUI [1,2]
C0038999
UMLS CUI [2,1]
C0021564
UMLS CUI [2,2]
C0332575
UMLS CUI [3,1]
C0021564
UMLS CUI [3,2]
C0033774
UMLS CUI [3,3]
C0205322
Specify reaction to insect bites
Description

Specify reaction to insect bites

Data type

text

Alias
UMLS CUI [1,1]
C0021564
UMLS CUI [1,2]
C0871764
UMLS CUI [1,3]
C1521902
Do you have regular contact with hay?
Description

Regular contact with hay

Data type

boolean

Alias
UMLS CUI [1,1]
C0332158
UMLS CUI [1,2]
C1440666
Do you have regular contact with flour?
Description

Regular contact with flour

Data type

boolean

Alias
UMLS CUI [1,1]
C0332158
UMLS CUI [1,2]
C0016260
Do you have regular contact with dust?
Description

Regular contact with dust

Data type

boolean

Alias
UMLS CUI [1,1]
C0332158
UMLS CUI [1,2]
C0013330
Do you have regular contact with cosmetics?
Description

Regular contact with cosmetics

Data type

boolean

Alias
UMLS CUI [1,1]
C0332158
UMLS CUI [1,2]
C0010164
Do you have regular contact with drugs?
Description

Regular contact with drugs

Data type

boolean

Alias
UMLS CUI [1,1]
C0332158
UMLS CUI [1,2]
C0013227
Do you live in an old-building flat/house or new building flat/house?
Description

Old-building flat/house or new building flat/house

Data type

integer

Alias
UMLS CUI [1,1]
C0457933
UMLS CUI [1,2]
C0580836
UMLS CUI [2,1]
C0457933
UMLS CUI [2,2]
C0205314
Have you ever had a hyposensitization?
Description

Hyposensitization

Data type

boolean

Alias
UMLS CUI [1]
C0178702
Specify the allergy to which the hyposensitization occurred and when it took place
Description

Specify the allergy to which the hyposensitization occurred and when it took place

Data type

text

Alias
UMLS CUI [1]
C0178702
UMLS CUI [2,1]
C0178702
UMLS CUI [2,2]
C0011008
Which drugs (including analgesics) do you take regulary?
Description

Drugs, including analgesics

Data type

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0002771
UMLS CUI [1,3]
C0205272
Do you smoke?
Description

If YES, specify number of cigarettes per day below.

Data type

boolean

Alias
UMLS CUI [1]
C0543414
Number of cigarettes per day
Description

Smoking number of cigarettes per day

Data type

integer

Alias
UMLS CUI [1,1]
C0543414
UMLS CUI [1,2]
C3694146
Do you do sports regularly?
Description

Regularly sports

Data type

boolean

Alias
UMLS CUI [1,1]
C0679823
UMLS CUI [1,2]
C0038039
UMLS CUI [1,3]
C0449581
Information about findings
Description

Information about findings

Alias
UMLS CUI-1
C1880174
Do you agree that we inform you about findings by e-mail or SMS?
Description

Information about findings per e-mail or SMS

Data type

boolean

Alias
UMLS CUI [1,1]
C1955348
UMLS CUI [1,2]
C0243095
UMLS CUI [1,3]
C0013849
UMLS CUI [1,4]
C3178909
Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Town
Description

Town

Data type

text

Alias
UMLS CUI [1]
C1555315
Signature
Description

Signature of patient

Data type

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Allergy Medical History (Allergieanamnese)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Surname
Item
Surname
text
C0421448 (UMLS CUI [1])
First name
Item
First name
text
C1443235 (UMLS CUI [1])
Health insurance
Item
Health insurance
text
C0021682 (UMLS CUI [1])
Adress
Item
Adress
text
C0421449 (UMLS CUI [1])
Telephone number
Item
Telephone number
integer
C1515258 (UMLS CUI [1])
Mobile phone number
Item
Mobile phone number
integer
C3273868 (UMLS CUI [1])
E-Mail adress
Item
E-Mail adress
text
C1705961 (UMLS CUI [1])
Date of visit
Item
Date
date
C1320303 (UMLS CUI [1])
Occupation
Item
Occupation
text
C0421456 (UMLS CUI [1])
General practitioner name
Item
General practitioner name
text
C0017319 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
General practitioner adress
Item
General practitioner adress
text
C0017319 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
Item Group
Current complaints
C0871764 (UMLS CUI-1)
C0521116 (UMLS CUI-2)
Item
Symptom
integer
C1457887 (UMLS CUI [1])
Symptom
Code List
Symptom
CL Item
eye inflammation / eye itching (1)
CL Item
Bronchitis / dyspnea (breathlessness) / cough (2)
CL Item
Urticaria (3)
CL Item
eczema (skin rash) (4)
CL Item
swellings (e.g. eyes, lips, tongue) (5)
CL Item
gastrointestinal complaints (6)
CL Item
sniff /sneezing (7)
Item
Temporal occurrence
integer
C2745955 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Temporal occurrence
Code List
Temporal occurrence
CL Item
perennial (1)
CL Item
spring (2)
CL Item
summer (3)
CL Item
winter (4)
Item Group
Medical History
C0262926 (UMLS CUI-1)
Do the complaints occur in the morning?
Item
Do the complaints occur in the morning?
boolean
C0871764 (UMLS CUI [1,1])
C2745955 (UMLS CUI [1,2])
C0332170 (UMLS CUI [1,3])
Do the complaints occur during daytime?
Item
Do the complaints occur during daytime?
boolean
C0871764 (UMLS CUI [1,1])
C2745955 (UMLS CUI [1,2])
C0332169 (UMLS CUI [1,3])
Do the complaints occur at night?
Item
Do the complaints occur at night?
boolean
C0871764 (UMLS CUI [1,1])
C2745955 (UMLS CUI [1,2])
C0240526 (UMLS CUI [1,3])
Are the complaints increasing in certain places?
Item
Are the complaints increasing in certain places?
boolean
C0871764 (UMLS CUI [1,1])
C0442808 (UMLS CUI [1,2])
C0014406 (UMLS CUI [1,3])
Specify, in which places complaints are increasing
Item
Specify, in which places complaints are increasing
text
C0871764 (UMLS CUI [1,1])
C0442808 (UMLS CUI [1,2])
C0014406 (UMLS CUI [1,3])
C1521902 (UMLS CUI [1,4])
Complaints in contact with animals
Item
Do you experience complaints when in contact with animals?
boolean
C0871764 (UMLS CUI [1,1])
C0332158 (UMLS CUI [1,2])
C0003062 (UMLS CUI [1,3])
Specify: in contact with which animals do complaints occur?
Item
Specify: in contact with which animals do complaints occur?
text
C0871764 (UMLS CUI [1,1])
C0332158 (UMLS CUI [1,2])
C0003062 (UMLS CUI [1,3])
C1521902 (UMLS CUI [1,4])
Have food intolerances been observed or known?
Item
Have food intolerances been observed or known?
boolean
C0020517 (UMLS CUI [1,1])
C0016452 (UMLS CUI [1,2])
Specify, which food intolerances have been observed or known.
Item
Specify, which food intolerances have been observed or known.
text
C0020517 (UMLS CUI [1,1])
C0016452 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Complaints during certain activities (e.g. sports, dusting)
Item
Do complaints arise during certain activities (e.g. sports, dusting)?
boolean
C0871764 (UMLS CUI [1,1])
C0026606 (UMLS CUI [1,2])
C0038039 (UMLS CUI [2])
C0563970 (UMLS CUI [3])
Specify, during which activity complaints arise.
Item
Specify, during which activity complaints arise.
text
C0871764 (UMLS CUI [1,1])
C0026606 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Increased swellings/rednesses/ persistent pruritus or other reactions to insect bites
Item
Were there any increased swellings/rednesses/ persistent itching or other reactions to insect bites? (mosquito, bee, wasp etc.)
boolean
C0021564 (UMLS CUI [1,1])
C0038999 (UMLS CUI [1,2])
C0021564 (UMLS CUI [2,1])
C0332575 (UMLS CUI [2,2])
C0021564 (UMLS CUI [3,1])
C0033774 (UMLS CUI [3,2])
C0205322 (UMLS CUI [3,3])
Specify reaction to insect bites
Item
Specify reaction to insect bites
text
C0021564 (UMLS CUI [1,1])
C0871764 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Regular contact with hay
Item
Do you have regular contact with hay?
boolean
C0332158 (UMLS CUI [1,1])
C1440666 (UMLS CUI [1,2])
Regular contact with flour
Item
Do you have regular contact with flour?
boolean
C0332158 (UMLS CUI [1,1])
C0016260 (UMLS CUI [1,2])
Regular contact with dust
Item
Do you have regular contact with dust?
boolean
C0332158 (UMLS CUI [1,1])
C0013330 (UMLS CUI [1,2])
Regular contact with cosmetics
Item
Do you have regular contact with cosmetics?
boolean
C0332158 (UMLS CUI [1,1])
C0010164 (UMLS CUI [1,2])
Regular contact with drugs
Item
Do you have regular contact with drugs?
boolean
C0332158 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Item
Do you live in an old-building flat/house or new building flat/house?
integer
C0457933 (UMLS CUI [1,1])
C0580836 (UMLS CUI [1,2])
C0457933 (UMLS CUI [2,1])
C0205314 (UMLS CUI [2,2])
Old-building flat/house or new building flat/house
Code List
Do you live in an old-building flat/house or new building flat/house?
CL Item
old-building flat/house (1)
CL Item
new-building flat/house (2)
Hyposensitization
Item
Have you ever had a hyposensitization?
boolean
C0178702 (UMLS CUI [1])
Specify the allergy to which the hyposensitization occurred and when it took place
Item
Specify the allergy to which the hyposensitization occurred and when it took place
text
C0178702 (UMLS CUI [1])
C0178702 (UMLS CUI [2,1])
C0011008 (UMLS CUI [2,2])
Drugs, including analgesics
Item
Which drugs (including analgesics) do you take regulary?
text
C0013227 (UMLS CUI [1,1])
C0002771 (UMLS CUI [1,2])
C0205272 (UMLS CUI [1,3])
Smoking
Item
Do you smoke?
boolean
C0543414 (UMLS CUI [1])
Smoking number of cigarettes per day
Item
Number of cigarettes per day
integer
C0543414 (UMLS CUI [1,1])
C3694146 (UMLS CUI [1,2])
Regularly sports
Item
Do you do sports regularly?
boolean
C0679823 (UMLS CUI [1,1])
C0038039 (UMLS CUI [1,2])
C0449581 (UMLS CUI [1,3])
Item Group
Information about findings
C1880174 (UMLS CUI-1)
Information about findings per e-mail or SMS
Item
Do you agree that we inform you about findings by e-mail or SMS?
boolean
C1955348 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0013849 (UMLS CUI [1,3])
C3178909 (UMLS CUI [1,4])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Town
Item
Town
text
C1555315 (UMLS CUI [1])
Signature of patient
Item
Signature
text
C1519316 (UMLS CUI [1])
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