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ID

42806

Description

Patient questionnaire to ODM format. Routine documentation of University Hospital of Münster. Publication granted by: Univ.-Prof. Dr. Dr.med. Gereon Heuft Klinik für Psychosomatik und Psychotherapie Universitätsklinikum Münster Domagkstr.22 48149 Münster

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Versions (2)
  1. 3/24/17 3/24/17 -
  2. 9/17/21 9/17/21 -
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September 17, 2021

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Creative Commons BY-NC 3.0
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    Patient questionnaire Psychosomatic medicine UKM

    German English

    Patient questionnaire

    1 forms  
    1. StudyEvent: ODM
      1. Patient questionnaire
    Patient demographics
    Description

    Patient demographics

    Patient name
    Description

    Patient name

    Data type

    text

    Alias
    UMLS CUI [1]
    C1299487 (Patient name)
    SNOMED
    371484003
    Address
    Description

    Address

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0421449 (Patient address)
    SNOMED
    184097001
    Telephone
    Description

    Telephone

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1515258 (Telephone Number)
    SNOMED
    734005006
    LOINC
    LP6871-0
    Relegion
    Description

    Religion

    Data type

    text

    Alias
    UMLS CUI [1]
    C0035039 (Religion)
    Gender
    Description

    Gender

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0079399 (Gender)
    SNOMED
    263495000
    LOINC
    LP61312-2
    Date of birth
    Description

    Date of birth

    Data type

    date

    Alias
    UMLS CUI [1]
    C0421451 (Patient date of birth)
    SNOMED
    184099003
    LOINC
    LP57552-9
    Nationality
    Description

    Nationality

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0027473 (Nationality)
    Family status
    Description

    Family status

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0682315 (status by family relationship)
    Partner
    Description

    Partner

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0682323 (Partner in relationship)
    SNOMED
    262043009
    LOINC
    LP76013-9
    In case of partnership
    Description

    In case of partnership

    Data type

    integer

    Symptoms
    Description

    Symptoms

    Alias
    UMLS CUI-1
    C1457887 (Symptoms)
    LOINC
    MTHU021540
    Please state current symptoms
    Description

    Symptoms

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1457887 (Symptoms)
    LOINC
    MTHU021540
    GP
    Description

    GP

    Alias
    UMLS CUI-1
    C0017319 (General Practitioners)
    SNOMED
    59058001
    Name of GP
    Description

    GP

    Data type

    text

    Alias
    UMLS CUI [1]
    C0017319 (General Practitioners)
    SNOMED
    59058001
    Address
    Description

    Address

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0421449 (Patient address)
    SNOMED
    184097001
    Telephone
    Description

    Telephone

    Data type

    integer

    Outpatient departement
    Description

    Outpatient departement

    Alias
    UMLS CUI-1
    C0557824 (Hospital-based outpatient department)
    SNOMED
    33022008
    Who has advised you to come to the outpatient department?
    Description

    Outpatient department

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0557824 (Hospital-based outpatient department)
    SNOMED
    33022008
    UMLS CUI [1,2]
    C0566251 (Reason and justification)
    SNOMED
    288830005
    Household
    Description

    Household

    Indicate the Person(s) living with
    Description

    Household

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0020052 (Households)
    Living arrangements
    Description

    Living arrangements

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0242487 (Living Arrangements)
    LOINC
    MTHU057057
    Qualifications
    Description

    Qualifications

    School degree
    Description

    Höchste(r) erreichte(r) Berufsabschluß/ Berufsausbildung:

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1709790 (Qualification)
    LOINC
    MTHU062001
    Vocational qualification
    Description

    Vocational qualification

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0013658 (Educational Status)
    SNOMED
    266981003
    Current occupation
    Description

    occupation

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0421456 (Patient occupation)
    SNOMED
    184104002
    Who earned the hightest income in your household?
    Description

    Job

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0021162 (Income)
    Employable
    Description

    Employable

    Data type

    boolean

    Retirement
    Description

    Retirement

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0035345 (Retirement)
    SNOMED
    105493001
    LOINC
    LA17991-3
    severe disability
    Description

    severe disability

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0424990 (Disability - severe)
    SNOMED
    161045001
    Work Capacity Evaluation
    Description

    Work Capacity Evaluation

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0043228 (Work Capacity Evaluation)
    Family history
    Description

    Family history

    Do you have any children?
    Description

    Children

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0008059 (Child)
    SNOMED
    410601007
    LOINC
    LA9949-4
    Name of Children
    Description

    Name of Children

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0008059 (Child)
    SNOMED
    410601007
    LOINC
    LA9949-4
    Siblings
    Description

    Siblings

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0037047 (Sibling)
    SNOMED
    375005
    LOINC
    LP33132-9
    Mother
    Description

    Mother

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0026591 (Mother (person))
    SNOMED
    72705000
    Father
    Description

    Father

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0015671 (Father (person))
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    Similar models

    Patient questionnaire

    1 forms
    1. StudyEvent: ODM
      1. Patient questionnaire
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Patient demographics
    Patient name
    Item
    Patient name
    text
    C1299487 (UMLS CUI [1])
    Address
    Item
    Address
    integer
    C0421449 (UMLS CUI [1])
    Telephone
    Item
    Telephone
    integer
    C1515258 (UMLS CUI [1])
    Religion
    Item
    Relegion
    text
    C0035039 (UMLS CUI [1])
    Item
    Gender
    integer
    C0079399 (UMLS CUI [1])
    Gender
    Code List
    Gender
    CL Item
    male (1)
    C1706180 (UMLS CUI-1)
    CL Item
    female (2)
    C0086287 (UMLS CUI-1)
    Date of birth
    Item
    Date of birth
    date
    C0421451 (UMLS CUI [1])
    Item
    Nationality
    integer
    C0027473 (UMLS CUI [1])
    Nationality
    Code List
    Nationality
    CL Item
    German (1)
    C1556085 (UMLS CUI-1)
    CL Item
    Other nationality (2)
    C0027473 (UMLS CUI-1)
    CL Item
    late repatriate (3)
    Item
    Family status
    integer
    C0682315 (UMLS CUI [1])
    Family status
    Code List
    Family status
    CL Item
    single (1)
    C0037179 (UMLS CUI-1)
    CL Item
    married (2)
    C0555047 (UMLS CUI-1)
    CL Item
    separated (3)
    C0086972 (UMLS CUI-1)
    CL Item
    divorced (4)
    C0086170 (UMLS CUI-1)
    CL Item
    widowed (5)
    C0206275 (UMLS CUI-1)
    CL Item
    re-married (6)
    C2114520 (UMLS CUI-1)
    Item
    Partner
    integer
    C0682323 (UMLS CUI [1])
    Partner
    Code List
    Partner
    CL Item
    no partner (1)
    C0420841 (UMLS CUI-1)
    CL Item
    steady partnership (2)
    C1711206 (UMLS CUI-1)
    CL Item
    promiscuous  (3)
    C0562558 (UMLS CUI-1)
    CL Item
    spouse (4)
    C3842295 (UMLS CUI-1)
    Item
    In case of partnership
    integer
    In case of partnership
    Code List
    In case of partnership
    CL Item
    Date of birth of partner (1)
    C0803906 (UMLS CUI-1)
    CL Item
    Job of partner (2)
    C0028811 (UMLS CUI-1)
    Item Group
    Symptoms
    C1457887 (UMLS CUI-1)
    Item
    Please state current symptoms
    integer
    C1457887 (UMLS CUI [1])
    Symptoms
    Code List
    Please state current symptoms
    CL Item
    Symptoms since when? (1)
    C3175529 (UMLS CUI-1)
    Item Group
    GP
    C0017319 (UMLS CUI-1)
    GP
    Item
    Name of GP
    text
    C0017319 (UMLS CUI [1])
    Address
    Item
    Address
    integer
    C0421449 (UMLS CUI [1])
    Telephone
    Item
    Telephone
    integer
    Item Group
    Outpatient departement
    C0557824 (UMLS CUI-1)
    Item
    Who has advised you to come to the outpatient department?
    integer
    C0557824 (UMLS CUI [1,1])
    C0566251 (UMLS CUI [1,2])
    Outpatient department
    Code List
    Who has advised you to come to the outpatient department?
    CL Item
    GP (1)
    C0017319 (UMLS CUI-1)
    CL Item
    Hospital (2)
    C0019994 (UMLS CUI-1)
    CL Item
    consultant (3)
    C0545082 (UMLS CUI-1)
    C0009817 (UMLS CUI-2)
    CL Item
    Psychotherapist (4)
    C0557555 (UMLS CUI-1)
    CL Item
    Advice center (5)
    CL Item
    Partner/ relative / friends (6)
    C3887537 (UMLS CUI-1)
    CL Item
    Myself (7)
    CL Item
    Other (8)
    C0205394 (UMLS CUI-1)
    Item Group
    Household
    Item
    Indicate the Person(s) living with
    integer
    C0020052 (UMLS CUI [1])
    Household
    Code List
    Indicate the Person(s) living with
    Item
    Living arrangements
    integer
    C0242487 (UMLS CUI [1])
    Living arrangements
    Code List
    Living arrangements
    CL Item
    Flat or house (1)
    C0457933 (UMLS CUI-1)
    CL Item
    home for the elderly (2)
    C0019870 (UMLS CUI-1)
    Item Group
    Qualifications
    Item
    School degree
    integer
    C1709790 (UMLS CUI [1])
    School degree
    Code List
    School degree
    CL Item
    no degree (1)
    Item
    Vocational qualification
    integer
    C0013658 (UMLS CUI [1])
    Vocational qualification
    Code List
    Vocational qualification
    CL Item
    Vocational qualification (1)
    C1709790 (UMLS CUI-1)
    CL Item
    University degree (2)
    C0041740 (UMLS CUI-1)
    CL Item
    no qualification (3)
    C0007836 (UMLS CUI-1)
    CL Item
    other (4)
    C0205394 (UMLS CUI-1)
    Item
    Current occupation
    integer
    C0421456 (UMLS CUI [1])
    occupation
    Code List
    Current occupation
    CL Item
    worker (1)
    C1306056 (UMLS CUI-1)
    CL Item
    employee (2)
    C0599987 (UMLS CUI-1)
    CL Item
    civil servant (3)
    C0401892 (UMLS CUI-1)
    CL Item
    self-employed (4)
    C0425092 (UMLS CUI-1)
    CL Item
    unemployed (5)
    C0041674 (UMLS CUI-1)
    Item
    Who earned the hightest income in your household?
    integer
    C0021162 (UMLS CUI [1])
    Job
    Code List
    Who earned the hightest income in your household?
    CL Item
    I live alone (1)
    CL Item
    worker (2)
    C1306056 (UMLS CUI-1)
    CL Item
    craftsman (3)
    CL Item
    employee (4)
    C0599987 (UMLS CUI-1)
    CL Item
    civil servant (5)
    C0401892 (UMLS CUI-1)
    Employable
    Item
    Employable
    boolean
    Item
    Retirement
    integer
    C0035345 (UMLS CUI [1])
    Retirement
    Code List
    Retirement
    CL Item
    no (1)
    C1298908 (UMLS CUI-1)
    CL Item
    pension application (2)
    C0185125 (UMLS CUI-1)
    Item
    severe disability
    integer
    C0424990 (UMLS CUI [1])
    severe disability
    Code List
    severe disability
    CL Item
    no (1)
    C1298908 (UMLS CUI-1)
    CL Item
    yes (2)
    C1705108 (UMLS CUI-1)
    CL Item
    degree (3)
    C0449438 (UMLS CUI-1)
    C0439792 (UMLS CUI-2)
    CL Item
    application (4)
    C0185125 (UMLS CUI-1)
    Work Capacity Evaluation
    Item
    Work Capacity Evaluation
    boolean
    C0043228 (UMLS CUI [1])
    Item Group
    Family history
    Children
    Item
    Do you have any children?
    boolean
    C0008059 (UMLS CUI [1])
    Item
    Name of Children
    integer
    C0008059 (UMLS CUI [1])
    Name of Children
    Code List
    Name of Children
    CL Item
    First name (1)
    C1443235 (UMLS CUI-1)
    CL Item
    Gender (2)
    C0079399 (UMLS CUI-1)
    CL Item
    Date of birth (3)
    C0421451 (UMLS CUI-1)
    CL Item
    In case of death: Cause of death (4)
    C0007465 (UMLS CUI-1)
    Siblings
    Item
    Siblings
    boolean
    C0037047 (UMLS CUI [1])
    Item
    Mother
    integer
    C0026591 (UMLS CUI [1])
    Mother
    Code List
    Mother
    CL Item
    date of birth (1)
    C0421451 (UMLS CUI-1)
    CL Item
    date of death (2)
    C1148348 (UMLS CUI-1)
    CL Item
    job (3)
    C0028811 (UMLS CUI-1)
    Item
    Father
    integer
    C0015671 (UMLS CUI [1])
    Mother
    Code List
    Father
    CL Item
    date of birth (1)
    C0421451 (UMLS CUI-1)
    CL Item
    date of death (2)
    C1148348 (UMLS CUI-1)
    CL Item
    job (3)
    C0028811 (UMLS CUI-1)
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