Date of completion
Item
Date of completion of this form
date
C0011008 (UMLS CUI [1])
Birth date
Item
Date of birth of High Risk Individual (HRI)
date
C0421451 (UMLS CUI [1])
Item
Sex
integer
C0079399 (UMLS CUI [1])
Item
What was the drug treatment which triggered the identification of patient?
integer
C0552502 (UMLS CUI [1])
Code List
What was the drug treatment which triggered the identification of patient?
CL Item
Antihypertensive therapy (1)
CL Item
Lipid-lowering therapy (2)
CL Item
Diabetes therapy (diet and/or oral hypoglycaemics and/or insulin) (3)
Item
History of hypertension
integer
C0035648 (UMLS CUI [1,1])
C0455527 (UMLS CUI [1,2])
Code List
History of hypertension
History of hypertension
Item
History of hypertension:if yes, Duration in months
integer
C0455527 (UMLS CUI [1])
Item
History of hyperlipidaemia/ dyslipidaemia
integer
C0035648 (UMLS CUI [1,1])
C0020473 (UMLS CUI [1,2])
C0242339 (UMLS CUI [2])
Code List
History of hyperlipidaemia/ dyslipidaemia
History of hyperlipidaemia/ dyslipidaemia
Item
History of hyperlipidaemia/ dyslipidaemia: If yes, duration in months
integer
C0262926 (UMLS CUI [1,1])
C0020473 (UMLS CUI [1,2])
C0242339 (UMLS CUI [2])
Item
History of diabetes
integer
C0035648 (UMLS CUI [1,1])
C0011847 (UMLS CUI [1,2])
Code List
History of diabetes
History of diabetes
Item
History of diabetes: If yes, duration in months
integer
C0455488 (UMLS CUI [1])
Item
Smoking status
integer
C0038586 (UMLS CUI [1])
CL Item
Is a current non smoker (but previous smoking history unknown) (2)
CL Item
Has stopped smoking (3)
CL Item
Current smoker (4)
Height
Item
Body height
float
C0005890 (UMLS CUI [1])
Weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
BMI
Item
Body Mass Index
float
C1305855 (UMLS CUI [1])
Waist circumference
Item
Waist circumference
float
C0455829 (UMLS CUI [1])
Systolic blood pressure
Item
Systolic blood pressure
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
Diastolic blood pressure
integer
C0428883 (UMLS CUI [1])
Heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Total cholesterol
Item
Total cholesterol
integer
C1445957 (UMLS CUI [1])
LDL cholesterol
Item
LDL cholesterol
integer
C0202117 (UMLS CUI [1])
HDL cholesterol
Item
HDL cholesterol
integer
C0428472 (UMLS CUI [1])
Triglycerides
Item
Triglycerides
integer
C0202236 (UMLS CUI [1])
Blood glucose level
Item
Blood glucose level
integer
C0392201 (UMLS CUI [1])
HbA1C
Item
HbA1C level (in diabetics)
float
C0202054 (UMLS CUI [1])
Item
Over the last 3 years, was the patient taking any of the following medications listed below?
integer
C0013227 (UMLS CUI [1])
Code List
Over the last 3 years, was the patient taking any of the following medications listed below?
Item
Aspirin or other anti-platelet drugs?
integer
C0004057 (UMLS CUI [1])
Code List
Aspirin or other anti-platelet drugs?
Generic name
Item
Aspirin or other anti-platelet drugs: Generic name
text
C0592502 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Aspirin: Total daily dose
Item
Aspirin or other anti-platelet drugs: Total daily dose
integer
C0004057 (UMLS CUI [1,1])
C0178602 (UMLS CUI [1,2])
Item
Aspirin or other anti-platelet drugs?
integer
C0004057 (UMLS CUI [1])
Code List
Aspirin or other anti-platelet drugs?
Generic name
Item
Aspirin or other anti-platelet drugs: Generic name
text
C0592502 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Aspirin: Total daily dose
Item
Aspirin or other anti-platelet drugs: Total daily dose
integer
C0004057 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Beta blockers
integer
C0304516 (UMLS CUI [1])
Generic name
Item
Beta blockers:Generic name
text
C0304516 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Beta Blockers: Total daily dose
Item
Beta Blockers Total daily dose
integer
C0304516 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
ACE inhibitors
integer
C0003015 (UMLS CUI [1])
Generic name
Item
ACE inhibitors: Generic name
text
C0003015 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
ACE inhibitors : Total daily dose
Item
ACE inhibitors : Total daily dose
integer
C0003015 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Angiotensin II receptor antagonists
integer
C0521942 (UMLS CUI [1])
Code List
Angiotensin II receptor antagonists
Generic name
Item
Angiotensin II receptor antagonists: Generic name
text
C0521942 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Angiotensin II receptor antagonists: Total daily dose
Item
Angiotensin II receptor antagonists: Total daily dose
integer
C0521942 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Calcium antagonists
integer
C0006684 (UMLS CUI [1])
Code List
Calcium antagonists
Generic name
Item
Calcium antagonists: Generic name
text
C0006684 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Calcium antagonists :Total daily dose
Item
Calcium antagonists: Total daily dose
integer
C0006684 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
If inhibitors
integer
C0257190 (UMLS CUI [1])
Generic name
Item
If inhibitors: Generic name
text
C0257190 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
If inhibitors : Total daily dose
Item
If inhibitors: Total daily dose
integer
C0257190 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Nitrates
integer
C0017887 (UMLS CUI [1])
Generic name
Item
Nitrates: Generic name
text
C0017887 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Nitrates: Total daily dose
Item
Nitrates: Total daily dose
integer
C0017887 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Diuretics
integer
C0012798 (UMLS CUI [1])
Generic name
Item
Diuretics: Generic name
text
C0012798 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Diuretics: Total daily dose
Item
Diuretics: Total daily dose
integer
C0012798 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Diuretics
integer
C0012798 (UMLS CUI [1])
Generic name
Item
Diuretics: Generic name
text
C0012798 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Diuretics: Total daily dose
Item
Diuretics: Total daily dose
integer
C0012798 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Other anti-hypertensive drugs
integer
C0003364 (UMLS CUI [1])
Code List
Other anti-hypertensive drugs
Generic name
Item
Other Anti-hypertensive drugs: Generic name
text
C0003364 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Anti-hypertensive drugs: Total daily dose
Item
Other Anti-hypertensive drugs: Total daily dose
integer
C0003364 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Digitalis glycosides
integer
C0012253 (UMLS CUI [1])
Code List
Digitalis glycosides
Generic name
Item
Digitalis glycosides: Generic name
text
C0012253 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Digitalis glycosides: Total daily dose
Item
Digitalis glycosides: Total daily dose
integer
C0012253 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Antiarrhythmics
integer
C0003195 (UMLS CUI [1])
Code List
Antiarrhythmics
Generic name
Item
Antiarrhythmics: Generic name
text
C0003195 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Antiarrhythmics: Total daily dose
Item
Antiarrhythmics: Total daily dose
integer
C0003195 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Lipid lowering drugs: Statins
integer
C0086440 (UMLS CUI [1])
Code List
Lipid lowering drugs: Statins
Generic name
Item
Lipid lowering drugs (Statins): Generic name
text
C0086440 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Lipid lowering drugs (Statins): Total daily dose
Item
Lipid lowering drugs (Statins): Total daily dose
integer
C0086440 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Lipid lowering drugs: Fibrates
integer
C0086440 (UMLS CUI [1])
Code List
Lipid lowering drugs: Fibrates
Generic name
Item
Lipid lowering drugs (Fibrates): Generic name
text
C0086440 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Lipid lowering drugs (Fibrates): Total daily dose
Item
Lipid lowering drugs (Fibrates): Total daily dose
integer
C0086440 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Lipid lowering drugs: Nicotinic acid group
integer
C0086440 (UMLS CUI [1])
Code List
Lipid lowering drugs: Nicotinic acid group
Generic name
Item
Lipid lowering drugs (Nicotinic acid group): Generic name
text
C0086440 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Lipid lowering drugs (Nicotinic acid group): Total daily dose
Item
Lipid lowering drugs (Nicotinic acid group): Total daily dose
integer
C0086440 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Lipid lowering drugs: Cholesterol absorption inhibitors
integer
C0086440 (UMLS CUI [1])
Code List
Lipid lowering drugs: Cholesterol absorption inhibitors
Generic name
Item
Lipid lowering drugs (Cholesterol absorption inhibitors): Generic name
text
C0086440 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Lipid lowering drugs (Cholesterol absorption inhibitors): Total daily dose
Item
Lipid lowering drugs (Cholesterol absorption inhibitors): Total daily dose
integer
C0086440 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Lipid lowering drugs: Resins
integer
C0086440 (UMLS CUI [1])
Code List
Lipid lowering drugs: Resins
Generic name
Item
Lipid lowering drugs (Resins): Generic name
text
C0086440 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Lipid lowering drugs (Resins): Total daily dose
Item
Lipid lowering drugs (Resins): Total daily dose
integer
C0086440 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Lipid lowering drugs: Other
integer
C0086440 (UMLS CUI [1])
Code List
Lipid lowering drugs: Other
Generic name
Item
Lipid lowering drugs (Other): Generic name
text
C0086440 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Lipid lowering drugs (Other): Total daily dose
Item
Lipid lowering drugs (Other): Total daily dose
integer
C0086440 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Anti-diabetic drugs: Insulin
integer
C0021641 (UMLS CUI [1])
Code List
Anti-diabetic drugs: Insulin
Generic name
Item
Insulin: Generic name
text
C0021641 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Insulin: Total daily dose
Item
Insulin: Total daily dose
integer
C0021641 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Anti-diabetic drugs: Insulin
integer
C0021641 (UMLS CUI [1])
Code List
Anti-diabetic drugs: Insulin
Generic name
Item
Insulin: Generic name
text
C0021641 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Insulin: Total daily dose
Item
Insulin: Total daily dose
integer
C0021641 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Anti-diabetic drugs: oral
integer
C0935929 (UMLS CUI [1])
Code List
Anti-diabetic drugs: oral
Generic name
Item
Oral Antidiabetics: Generic name
text
C0935929 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Oral Antidiabetics: Total daily dose
Item
Oral Antidiabetics: Total daily dose
integer
C0935929 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Anti-diabetic drugs: oral
integer
C0935929 (UMLS CUI [1])
Code List
Anti-diabetic drugs: oral
Generic name
Item
Oral Antidiabetics: Generic name
text
C0935929 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Oral Antidiabetics: Total daily dose
Item
Oral Antidiabetics: Total daily dose
integer
C0935929 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Anti-coagulants
integer
C0003280 (UMLS CUI [1])
Code List
Anti-coagulants
Generic name
Item
Anti-coagulants: Generic name
text
C0003280 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Anti-coagulants: Total daily dose
Item
Anti-coagulants: Total daily dose
integer
C0003280 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Oral contraceptive pill
integer
C0009905 (UMLS CUI [1])
Code List
Oral contraceptive pill
Generic name
Item
Oral contraceptive pill: Generic name
text
C0009905 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Oral contraceptives: Total daily dose
Item
Oral contraceptive pill: Total daily dose
text
C0009905 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Hormone replacement therapy
integer
C0282402 (UMLS CUI [1])
Code List
Hormone replacement therapy
Generic name
Item
Hormone replacement therapy: Generic name
text
C0282402 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Hormone replacement therapy: Total daily dose
Item
Hormone replacement therapy: Total daily dose
text
C0282402 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Appetite suppressants or other antiobesity
integer
C0003620 (UMLS CUI [1])
C0376607 (UMLS CUI [2])
Code List
Appetite suppressants or other antiobesity
Generic name
Item
Appetite suppressants/other antiobesity: Generic name
text
C0003620 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
C0376607 (UMLS CUI [2,1])
C0592502 (UMLS CUI [2,2])
Appetite suppressants or other antiobesity: Total daily dose
Item
Appetite suppressants or other antiobesity: Total daily dose
integer
C0003620 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
C0376607 (UMLS CUI [2,1])
C2348070 (UMLS CUI [2,2])
Item
Nicotine replacement therapy
integer
C1278444 (UMLS CUI [1])
Code List
Nicotine replacement therapy
Generic name
Item
Nicotine replacement therapy: Generic name
text
C1278444 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Nicotine replacement therapy: Total daily dose
Item
Nicotine replacement therapy: Total daily dose
integer
C1278444 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Nicotine replacement therapy
integer
C1278444 (UMLS CUI [1])
Code List
Nicotine replacement therapy
Item
Bupropion
integer
C0085208 (UMLS CUI [1])
Generic name
Item
Bupropion: Generic name
text
C0085208 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Bupropion: Total daily dose
Item
Bupropion: Total daily dose
integer
C0085208 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Item
Other medication
integer
C0013227 (UMLS CUI [1])
Code List
Other medication
Generic name
Item
Other medications: Generic name
text
C0013227 (UMLS CUI [1,1])
C0592502 (UMLS CUI [1,2])
Other medications: Total daily dose
Item
Other medications: Total daily dose
integer
C0013227 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Item
Is any of the medication prescribed a combination of 2 drugs in one tablet?
integer
C0013227 (UMLS CUI [1])
Code List
Is any of the medication prescribed a combination of 2 drugs in one tablet?
CL Item
Don´t know/Unsure (3)
Pharmaceutical preparations
Item
If yes, please specify
text
C0013227 (UMLS CUI [1])
Completion
Item
High Risk Individual Record Form completed
boolean
C0805732 (UMLS CUI [1])