Inglés

Baseline Patient-reported Form

1 formularios  
Administrative Data
Descripción

Administrative Data

Alias
UMLS CUI-1
C1320722
Indicate the patient's medical record number
Descripción

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

Tipo de datos

integer

Alias
UMLS CUI [1]
C1269815
Patient's last name:
Descripción

The patients' name will not be shared with ICHOM.  INCLUSION CRITERIA: All patients TIMING: On all forms REPORTING SOURCE: Administrative or clinical

Tipo de datos

text

Alias
UMLS CUI [1]
C1299487
Demographic Factors
Descripción

Demographic Factors

Alias
UMLS CUI-1
C1704791
Please indicate your sex at birth:
Descripción

INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Single answer

Tipo de datos

integer

Alias
UMLS CUI [1]
C0079399
What is your date of birth?
Descripción

INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported

Tipo de datos

date

Unidades de medida
  • DD/MM/YYYY
Alias
UMLS CUI [1]
C0421451
DD/MM/YYYY
Varies by country and should be determined by country (not for cross country comparison)
Descripción

INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Single answer

Tipo de datos

integer

Alias
UMLS CUI [1]
C0015031
Please indicate highest level of schooling completed. This response option is based upon the ISCED for the United States, and reflects standards in the U.S. Please adapt questions according to your country’s guidelines.
Descripción

This is based upon the International Standard Classification of Education for the United States, and reflects standards in the U.S. Please adapt questions according to your country’s guidelines. Primary refers to the first 8 years of formal education in elementary school in the US. Secondary school refers to the last four years of statutory formal education (grade 9-12) at high school in the US. Tertiary refers to colleges or universities, including undergraduate and postgraduate education in the US. INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Single answer

Tipo de datos

integer

Alias
UMLS CUI [1]
C0013658
What is your relationship status?
Descripción

INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Single answer

Tipo de datos

integer

Alias
UMLS CUI [1]
C0439849
Baseline Clinical Factors
Descripción

Baseline Clinical Factors

Alias
UMLS CUI-1
C0449440
UMLS CUI-2
C1442488
Do you have any of the following problems? 0 = I have no other diseases
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0549184
Do you have any of the following problems? 1 = Heart disease (for example: angina, heart attack, or heart failure)
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0018799
Do you have any of the following problems? 2 = High blood pressure
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0020538
Do you have any of the following problems? 3 = Leg pain when walking due to poor circulation
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C1306889
Do you have any of the following problems? 4 = Lung disease (For example, asthma, chronic bronchitis, or emphysema)
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0024115
Do you have any of the following problems? 5 = Diabetes
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0011849
Do you have any of the following problems? 6 = Kidney disease
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0022658
Do you have any of the following problems? 7 = Liver disease
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0023895
Do you have any of the following problems? 8 = Problems caused by stroke
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0038454
Do you have any of the following problems? 9 = Disease of the nervous system (For example, Parkinson’s disease or multiple sclerosis)
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0027765
Do you have any of the following problems? 10 = Other cancer (within the last 5 years)
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C1707251
Do you have any of the following problems? 11 = Depression
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0011581
Do you have any of the following problems? 12 = Arthritis
Descripción

Based upon the Self-administered Comorbidity Questionnaire (Sangha et al, 2003) INCLUSION CRITERIA: All patients TIMING: Baseline REPORTING SOURCE: Patient-reported TYPE: Multiple answer Separate multiple entries with ";"

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0003864
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Similar models

Baseline Patient-reported Form

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Patient ID
Item
Indicate the patient's medical record number
integer
C1269815 (UMLS CUI [1])
Patient's last name
Item
Patient's last name:
text
C1299487 (UMLS CUI [1])
Item Group
Demographic Factors
C1704791 (UMLS CUI-1)
Item
Please indicate your sex at birth:
integer
C0079399 (UMLS CUI [1])
Gender
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)
Date of birth
Item
What is your date of birth?
date
C0421451 (UMLS CUI [1])
Ethnicity
Item
Varies by country and should be determined by country (not for cross country comparison)
integer
C0015031 (UMLS CUI [1])
Item
Please indicate highest level of schooling completed. This response option is based upon the ISCED for the United States, and reflects standards in the U.S. Please adapt questions according to your country’s guidelines.
integer
C0013658 (UMLS CUI [1])
Educational Level
Code List
Please indicate highest level of schooling completed. This response option is based upon the ISCED for the United States, and reflects standards in the U.S. Please adapt questions according to your country’s guidelines.
CL Item
None (0)
C0557286 (UMLS CUI-1)
(Comment:en)
CL Item
Primary (1)
C0557287 (UMLS CUI-1)
(Comment:en)
CL Item
Secondary (2)
C0557289 (UMLS CUI-1)
(Comment:en)
CL Item
Tertiary (3)
C0557291 (UMLS CUI-1)
(Comment:en)
Item
What is your relationship status?
integer
C0439849 (UMLS CUI [1])
Educational Level
Code List
What is your relationship status?
CL Item
Never married/partnered (0)
C0027952 (UMLS CUI-1)
(Comment:en)
CL Item
Married/partnered (1)
C0555047 (UMLS CUI-1)
C1546497 (UMLS CUI-2)
(Comment:en)
CL Item
Divorced/separated (2)
C0682073 (UMLS CUI-1)
(Comment:en)
CL Item
Widowed (3)
C0206275 (UMLS CUI-1)
(Comment:en)
Item Group
Baseline Clinical Factors
C0449440 (UMLS CUI-1)
C1442488 (UMLS CUI-2)
Comorbidities: None
Item
Do you have any of the following problems? 0 = I have no other diseases
boolean
C0009488 (UMLS CUI [1,1])
C0549184 (UMLS CUI [1,2])
Comorbidities: Heart disease
Item
Do you have any of the following problems? 1 = Heart disease (for example: angina, heart attack, or heart failure)
boolean
C0009488 (UMLS CUI [1,1])
C0018799 (UMLS CUI [1,2])
Comorbidities: High Blood Pressure
Item
Do you have any of the following problems? 2 = High blood pressure
boolean
C0009488 (UMLS CUI [1,1])
C0020538 (UMLS CUI [1,2])
Comorbidities: peripheral occlusive arterial disease
Item
Do you have any of the following problems? 3 = Leg pain when walking due to poor circulation
boolean
C0009488 (UMLS CUI [1,1])
C1306889 (UMLS CUI [1,2])
Comorbidities: Lung disease
Item
Do you have any of the following problems? 4 = Lung disease (For example, asthma, chronic bronchitis, or emphysema)
boolean
C0009488 (UMLS CUI [1,1])
C0024115 (UMLS CUI [1,2])
Comorbidities: Diabetes
Item
Do you have any of the following problems? 5 = Diabetes
boolean
C0009488 (UMLS CUI [1,1])
C0011849 (UMLS CUI [1,2])
Comorbidities: Kidney disease
Item
Do you have any of the following problems? 6 = Kidney disease
boolean
C0009488 (UMLS CUI [1,1])
C0022658 (UMLS CUI [1,2])
Comorbidities: Liver disease
Item
Do you have any of the following problems? 7 = Liver disease
boolean
C0009488 (UMLS CUI [1,1])
C0023895 (UMLS CUI [1,2])
Comorbidities: stroke
Item
Do you have any of the following problems? 8 = Problems caused by stroke
boolean
C0009488 (UMLS CUI [1,1])
C0038454 (UMLS CUI [1,2])
Comorbidities: Disease of the nervous system
Item
Do you have any of the following problems? 9 = Disease of the nervous system (For example, Parkinson’s disease or multiple sclerosis)
boolean
C0009488 (UMLS CUI [1,1])
C0027765 (UMLS CUI [1,2])
Comorbidities: Other Cancer
Item
Do you have any of the following problems? 10 = Other cancer (within the last 5 years)
boolean
C0009488 (UMLS CUI [1,1])
C1707251 (UMLS CUI [1,2])
Comorbidities: Depression
Item
Do you have any of the following problems? 11 = Depression
boolean
C0009488 (UMLS CUI [1,1])
C0011581 (UMLS CUI [1,2])
Comorbidities: Arthritis
Item
Do you have any of the following problems? 12 = Arthritis
boolean
C0009488 (UMLS CUI [1,1])
C0003864 (UMLS CUI [1,2])
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