ID

5582

Description

Form from HIS OpenVistA

Keywords

  1. 2/18/12 2/18/12 -
  2. 8/7/14 8/7/14 - Martin Dugas
  3. 8/9/14 8/9/14 - Martin Dugas
  4. 6/26/15 6/26/15 - Martin Dugas
Uploaded on

August 9, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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HIS HEALTH HISTORY I_ANESTHESIA MULTIDISCIPLINARY

  1. StudyEvent: HIS
    1. HIS
Overview
Description

Overview

Age
Description

Age

Data type

string

Alias
UMLS CUI 2011AA
C0001779
SNOMED CT 2011_0131
397669002
Height
Description

Height

Data type

string

Alias
UMLS CUI-1
C0005890
LOINC Version 232
MTHU005354
Weight
Description

Weight

Data type

string

Alias
UMLS
C0005910
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
Temperature
Description

Temperature

Data type

string

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
Pulse Rate
Description

Pulse Rate

Data type

string

Alias
UMLS CUI 2011AA
C0232117
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
Respiration rate, Breathing rate (BR)
Description

Respiratory rate

Data type

string

Alias
UMLS CUI 2011AA
C0231832
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
Blood pressure (BP)
Description

Blood Pressure

Data type

string

Alias
UMLS CUI 2011AA
C0005823
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
PT'S RESIDENCE
Description

PT'S RESIDENCE

Data type

string

LANGUAGE/COMMUNICATION BARRIER
Description

LANGUAGE/COMMUNICATION BARRIER

Data type

string

PRIMARY LANGUAGE
Description

PRIMARY LANGUAGE

Data type

string

Chief complaint (CC)
Description

CHIEF COMPLAINT

Data type

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
General practitioner (GP)
Description

Primary Care Physician (PCP)

Data type

string

Alias
UMLS CUI 2011AA
C0033131, C0017319
SNOMED CT 2011_0131
446050000, 59058001
HL7 V3 2006_05
PCP
Anesthesia Specific
Description

Anesthesia Specific

Hypersensitivities
Description

Allergies

Data type

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
ICD-10-CM Version 2010
T78.40
Are you allergic to adhesive tape?
Description

Are you allergic to adhesive tape?

Data type

boolean

Are you allergic to rubber products?
Description

Are you allergic to rubber products?

Data type

boolean

Previous Surgeries?
Description

Previous Surgeries?

Data type

string

Surgery involving an anesthetic?
Description

Surgery involving an anesthetic?

Data type

string

General anaesthesia (GA)
Description

General Anesthesia

Data type

boolean

Alias
UMLS CUI 2011AA
C0002915
SNOMED CT 2011_0131
50697003
MedDRA 14.1
10018060
Spinal Anaesthesia
Description

Spinal Anesthesia

Data type

boolean

Alias
UMLS CUI 2011AA
C0002928
SNOMED CT 2011_0131
231249005
MedDRA 14.1
10041536
epidural anesthesia
Description

Epidural anaesthesia

Data type

boolean

Alias
UMLS CUI 2011AA
C0002913
SNOMED CT 2011_0131
18946005
MedDRA 14.1
10015011
Regional Anesthesia Procedure
Description

Regional anesthesia

Data type

boolean

Alias
UMLS CUI 2011AA
C0002911
SNOMED CT 2011_0131
27372005
Local anaesthesia (LA)
Description

Local anesthesia

Data type

boolean

Alias
UMLS CUI 2011AA
C0002921
SNOMED CT 2011_0131
386761002
MedDRA 14.1
10024758
anesthetic: Moderate sedation
Description

anesthetic: Moderate sedation

Data type

boolean

anesthetic: Axillary block
Description

anesthetic: Axillary block

Data type

boolean

Have you or a family member ever had a problem with an anesthesic? If Yes, describe:
Description

Have you or a family member ever had a problem with an anesthesic? If Yes, describe:

Data type

string

Health History - Endocrine
Description

Health History - Endocrine

Diabetes mellitus
Description

Diabetes

Data type

boolean

Alias
UMLS CUI 2011AA
C0011849
SNOMED CT 2011_0131
191044006
If Diabetes, last time med taken
Description

If Diabetes, last time med taken

Data type

string

Hyperthyroidism
Description

Hyperthyroidism

Data type

boolean

Alias
UMLS CUI 2011AA
C0020550
SNOMED CT 2011_0131
34486009
MedDRA 14.1
10020850
LOINC Version 232
MTHU020782
ICD-10-CM Version 2010
E05.9
ICD-9-CM Version 2011
242.9
CTCAE 1105E
E10322
Hypothyroidism
Description

Hypothyroidism

Data type

boolean

Alias
UMLS CUI 2011AA
C0020676
SNOMED CT 2011_0131
40930008
MedDRA 14.1
10021114
LOINC Version 232
MTHU020783
ICD-10-CM Version 2010
E03.9
ICD-9-CM Version 2011
244.9
CTCAE 1105E
E10334
Health History - Neurologic
Description

Health History - Neurologic

Cerebrovascular accident (CVA)
Description

CVA/Stroke/TIA

Data type

string

Alias
UMLS CUI 2011AA
C0038454
SNOMED CT 2011_0131
230690007
MedDRA 14.1
10042244
ICD-10-CM Version 2010
I63.9
CTCAE 1105E
E12826
Convulsion
Description

Seizures

Data type

string

Alias
UMLS CUI 2011AA
C0036572
SNOMED CT 2011_0131
91175000
MedDRA 14.1
10039910
ICD-9-CM Version 2011
780.39
Loss of Sensation
Description

Numbness/Tingling to Arms/Legs

Data type

string

Alias
UMLS CUI 2011AA
C0028643
SNOMED CT 2011_0131
44077006
MedDRA 14.1
10029829
ICD-9-CM Version 2011
782.0
Migraines and/or Headaches
Description

Migraines and/or Headaches

Data type

string

Alias
UMLS CUI 2011AA
C0149931, C0018681
SNOMED CT 2011_0131
37796009, 25064002
MedDRA 14.1
10027599,1
LOINC Version 232
MTHU020860
ICD-10-CM Version 2010
G43, R51
ICD-9-CM Version 2011
346, 784.0
CTCAE 1105E
E12678
Blackout or Fainting Spells
Description

Blackout or Fainting Spells

Data type

string

Alias
UMLS CUI 2011AA
C0312422
SNOMED CT 2011_0131
418648005
MedDRA 14.1
10004982
ICD-10-CM Version 2010
R55
ICD-9-CM Version 2011
780.2
Health History - Cardiovascular
Description

Health History - Cardiovascular

Heart Attack/MI
Description

Heart Attack/MI

Data type

string

Alias
UMLS CUI 2011AA
C0027051
SNOMED CT 2011_0131
22298006
MedDRA 14.1
10028596
LOINC Version 232
MTHU035551
ICD-10-CM Version 2010
I21-I22
ICD-9-CM Version 2011
410
CTCAE 1105E
E10152
Hypertension
Description

High Blood Pressure

Data type

string

Alias
UMLS CUI 2011AA
C0020538
SNOMED CT 2011_0131
38341003
MedDRA 14.1
10020772
LOINC Version 232
MTHU020789
ICD-10-CM Version 2010
I10
ICD-9-CM Version 2011
997.91
CTCAE 1105E
E13785
Rapid heart beat, high heart frequency, heart rate increased
Description

Rapid Heart Rate

Data type

string

Alias
UMLS CUI 2011AA
C0039231
SNOMED CT 2011_0131
3424008
MedDRA 14.1
10019303
ICD-10-CM Version 2010
R00.0
ICD-9-CM Version 2011
785.0
Cardiac Arrhythmia
Description

Irregular Heart Beat

Data type

string

Alias
UMLS CUI 2011AA
C0003811
SNOMED CT 2011_0131
44808001
MedDRA 14.1
10003119
ICD-9-CM Version 2011
427.9
Disease affecting entire cardiovascular system
Description

Cardiovascular Disease, Stents, Angioplasty, Heart Catherization

Data type

string

Alias
UMLS CUI 2011AA
C0007222
SNOMED CT 2011_0131
105980002
MedDRA 14.1
10007649
ICD-9-CM Version 2011
429.2
Ischemic chest pain
Description

Chest Pain/Angina

Data type

string

Alias
UMLS CUI 2011AA
C0002962
SNOMED CT 2011_0131
194828000
MedDRA 14.1
10002383
ICD-10-CM Version 2010
I20
ICD-9-CM Version 2011
413
Health History - Respiratory
Description

Health History - Respiratory

Lung diseases
Description

Lung Disease

Data type

string

Alias
UMLS CUI 2011AA
C0024115
SNOMED CT 2011_0131
19829001
MedDRA 14.1
10025082
ICD-10-CM Version 2010
J98.4
Chronic congestive heart failure
Description

Congestive Heart Failure

Data type

string

Alias
UMLS CUI 2011AA
C0264722
SNOMED CT 2011_0131
42343007
MedDRA 14.1
10007559
LOINC Version 232
MTHU020787
ICD-10-CM Version 2010
I50
ICD-9-CM Version 2011
428
Chronic cough
Description

Chronic Cough

Data type

string

Alias
UMLS CUI 2011AA
C0010201
SNOMED CT 2011_0131
68154008
MedDRA 14.1
10066656
Asthma
Description

Asthma/Wheezing

Data type

string

Alias
UMLS CUI 2011AA
C0004096
SNOMED CT 2011_0131
195967001
MedDRA 14.1
10003553
LOINC Version 232
MTHU020815
ICD-10-CM Version 2010
J45
ICD-9-CM Version 2011
493
Chronic Obstructive Pulmonary Disease, Bronchial infection, Pulmonary Emphysema
Description

COPD/Bronchitis/Emphysema

Data type

string

Alias
UMLS CUI 2011AA
C0024117, C0006277, C0034067
SNOMED CT 2011_0131
13645005, 32398004, 87433001
MedDRA 14.1
10009033, 10006451, 10014561
ICD-10-CM Version 2010
J44.9, J40, J43
ICD-9-CM Version 2011
496, 490, 492
CTCAE 1105E
E11323
Pneumonitis
Description

Pneumonia

Data type

string

Alias
UMLS CUI 2011AA
C0032285
SNOMED CT 2011_0131
233604007
MedDRA 14.1
10035664
LOINC Version 232
MTHU020831
ICD-10-CM Version 2010
J18.9
CTCAE 1105E
E13502
Health History - Genitourinary
Description

Health History - Genitourinary

Abnormal Kidney function
Description

Abnormal Kidney function

Data type

string

Alias
UMLS CUI 2011AA
C1565489
MedDRA 14.1
10038474
Haemodialysis
Description

On Hemodialysis

Data type

boolean

Alias
UMLS CUI 2011AA
C0019004
SNOMED CT 2011_0131
302497006
MedDRA 14.1
10018875
ICD-10-CM Version 2010
E71.43
ICD-9-CM Version 2011
39.95
Peritoneal Dialysis (PD)
Description

On Peritoneal Dialysis

Data type

boolean

Alias
UMLS CUI 2011AA
C0031139
SNOMED CT 2011_0131
71192002
MedDRA 14.1
10034660
ICD-9-CM Version 2011
54.98
Health History - Gastrointestinal
Description

Health History - Gastrointestinal

Icterus
Description

Yellow Jaundice

Data type

string

Alias
UMLS CUI 2011AA
C0022346
SNOMED CT 2011_0131
18165001
MedDRA 14.1
10023126
ICD-10-CM Version 2010
R17
Hepatitis
Description

Hepatitis/Liver Disease

Data type

string

Alias
UMLS CUI 2011AA
C0019158
SNOMED CT 2011_0131
29001004
MedDRA 14.1
10019717
gastric reflux
Description

Freq. Indigestion/Reflux Disease

Data type

string

Alias
UMLS CUI 2011AA
C0558176
SNOMED CT 2011_0131
225587003
Peptic Ulcer
Description

Gastric Ulcers

Data type

string

Alias
UMLS CUI 2011AA
C0030920
SNOMED CT 2011_0131
13200003
MedDRA 14.1
10034341
ICD-10-CM Version 2010
K27
ICD-9-CM Version 2011
533
Health History - Other
Description

Health History - Other

Bleeding diathesis
Description

Bleed or Bruise Easily

Data type

string

Alias
UMLS CUI 2011AA
C1458140
SNOMED CT 2011_0131
248250000
MedDRA 14.1
10005134
Transfusion
Description

Blood Transfusions

Data type

string

Alias
UMLS CUI 2011AA
C1879316
SNOMED CT 2011_0131
5447007
MedDRA 14.1
10066152
Malignant Neoplasms
Description

Cancer

Data type

string

Alias
UMLS CUI 2011AA
C0006826
SNOMED CT 2011_0131
363346000
MedDRA 14.1
10028997
LOINC Version 232
MTHU010328
ICD-10-CM Version 2010
C00-C96
Bleeding Disorders
Description

Bleeding Disorders

Data type

string

SAS - Sleep apnea syndrome
Description

Obstructive Sleep Apnea

Data type

string

Alias
UMLS CUI 2011AA
C0037315
SNOMED CT 2011_0131
73430006
MedDRA 14.1
10040979
ICD-10-CM Version 2010
G47.30
ICD-9-CM Version 2011
780.57
CTCAE 1105E
E13566
HAVE YOU HAD ANY MAJOR ILLNESS
Description

HAVE YOU HAD ANY MAJOR ILLNESS

Data type

string

DO YOU HAVE DENTURES
Description

DO YOU HAVE DENTURES

Data type

boolean

DO YOU HAVE BRIDGEWORK
Description

DO YOU HAVE BRIDGEWORK

Data type

boolean

DO YOU HAVE CAPPED TEETH
Description

DO YOU HAVE CAPPED TEETH

Data type

boolean

DO YOU HAVE LOOSE TEETH
Description

DO YOU HAVE LOOSE TEETH

Data type

boolean

Medication
Description

Are you taking any medications NOW?

Data type

string

Alias
UMLS CUI 2011AA
C0013227
Steroids
Description

Have you taken steroids in the last 6 months?

Data type

string

Alias
UMLS CUI 2011AA
C0038317
SNOMED CT 2011_0131
116566001
Health History - Women's health
Description

Health History - Women's health

DATE OF LAST PERIOD
Description

DATE OF LAST PERIOD

Data type

date

pregnant
Description

Are pregnant?

Data type

boolean

Alias
UMLS CUI 2011AA
C0549206
MedDRA 14.1
10036586
Weeks Gestation
Description

Weeks Gestation

Data type

integer

Estimated date of confinement (delivery date)
Description

EDC

Data type

date

Health History - Substance abuse and Smoking
Description

Health History - Substance abuse and Smoking

Substance abuse problem
Description

Substance abuse

Data type

string

Alias
UMLS CUI 2011AA
C0740858
SNOMED CT 2011_0131
66214007
MedDRA 14.1
10066169
LOINC Version 232
MTHU019364
Smoker
Description

Do you currently smoke/use tobacco products?

Data type

boolean

Alias
UMLS CUI 2011AA
CL025861
What type of tobacco products?
Description

What type of tobacco products?

Data type

string

How much?
Description

How much?

Data type

string

Have you ever smoked /used tobacco products?
Description

Have you ever smoked /used tobacco products?

Data type

boolean

When did you quit?(If has used products in the past 12 months,MUST give smoking cessation advice/information)
Description

When did you quit?(If has used products in the past 12 months,MUST give smoking cessation advice/information)

Data type

date

What type of tobacco products?
Description

What type of tobacco products?

Data type

string

How much?
Description

How much?

Data type

string

Pediatric Smoking: Does anyone in your household currently use tobacco products?
Description

Pediatric Smoking: Does anyone in your household currently use tobacco products?

Data type

boolean

What type of tobacco products?
Description

What type of tobacco products?

Data type

string

How much?
Description

How much?

Data type

string

Has anyone in the house hold quit using tobacco products in the last 12 months?
Description

Has anyone in the house hold quit using tobacco products in the last 12 months?

Data type

boolean

When did the person in your house hold quit?(If has used products in the past 12 months, MUST give smoking cessation advice/information)
Description

When did the person in your house hold quit?(If has used products in the past 12 months, MUST give smoking cessation advice/information)

Data type

date

What type of tobacco products?
Description

What type of tobacco products?

Data type

string

How much?
Description

How much?

Data type

string

Tobacco/Smoking Cessation information/advice given to Patient
Description

Tobacco/Smoking Cessation information/advice given to Patient

Data type

boolean

Tobacco/Smoking Cessation information/advice given to Other
Description

Tobacco/Smoking Cessation information/advice given to Other

Data type

boolean

In what format was the smoking cessation given (Verbal, Handwritten, Pre-printed)?
Description

In what format was the smoking cessation given (Verbal, Handwritten, Pre-printed)?

Data type

integer

How much alcohol?
Description

How much alcohol?

Data type

string

How often alcohol?
Description

How often alcohol?

Data type

string

RECREATIONAL DRUGS
Description

RECREATIONAL DRUGS

Data type

string

Immunizations
Description

Immunizations

Immunisation
Description

Immunizations

Data type

string

Alias
UMLS CUI 2011AA
C0020971
SNOMED CT 2011_0131
127785005
MedDRA 14.1
10021431
HL7 V3 2006_05
IMMUNIZ
SPECIALTY CLINIC specific
Description

SPECIALTY CLINIC specific

SPECIALTY CLINIC specific
Description

SPECIALTY CLINIC specific

Data type

string

Nutrition
Description

Nutrition

Current Weight
Description

Current Weight

Data type

integer

Have you experienced any unexplained weight loss or gain in the past 6 months?
Description

Have you experienced any unexplained weight loss or gain in the past 6 months?

Data type

boolean

As compared to normal, would you rate your food intake during the past month as either: CHANGED- MORE- LESS
Description

As compared to normal, would you rate your food intake during the past month as either: CHANGED- MORE- LESS

Data type

integer

Assistance / Mobility
Description

Assistance / Mobility

Do you live alone?
Description

Do you live alone?

Data type

boolean

Needs assistance at home
Description

Does anyone assist you at home?

Data type

boolean

Alias
UMLS CUI 2011AA
C0578564
SNOMED CT 2011_0131
301887005
If yes, Name and phone number of person and/or facility that assists
Description

If yes, Name and phone number of person and/or facility that assists

Data type

string

Equipment needed for WOUND(S)
Description

Equipment needed for WOUND(S)

Data type

string

Wound
Description

Where is your wound(s) located?

Data type

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
How long have you had the wound(s)?
Description

How long have you had the wound(s)?

Data type

date

How did the wounds start?
Description

How did the wounds start?

Data type

string

How have you been treating the wound(s)?
Description

How have you been treating the wound(s)?

Data type

string

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Overview
Age
Item
Age
string
C0001779 (UMLS CUI 2011AA)
397669002 (SNOMED CT 2011_0131)
Height
Item
Height
string
C0005890 (UMLS CUI-1)
MTHU005354 (LOINC Version 232)
Weight
Item
Weight
string
C0005910 (UMLS)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
Temperature
Item
Temperature
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
Pulse Rate
Item
Pulse Rate
string
C0232117 (UMLS CUI 2011AA)
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
Respiratory rate
Item
Respiration rate, Breathing rate (BR)
string
C0231832 (UMLS CUI 2011AA)
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
Blood Pressure
Item
Blood pressure (BP)
string
C0005823 (UMLS CUI 2011AA)
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
PT'S RESIDENCE
Item
PT'S RESIDENCE
string
LANGUAGE/COMMUNICATION BARRIER
Item
LANGUAGE/COMMUNICATION BARRIER
string
PRIMARY LANGUAGE
Item
PRIMARY LANGUAGE
string
CHIEF COMPLAINT
Item
Chief complaint (CC)
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
Primary Care Physician (PCP)
Item
General practitioner (GP)
string
C0033131, C0017319 (UMLS CUI 2011AA)
446050000, 59058001 (SNOMED CT 2011_0131)
PCP (HL7 V3 2006_05)
Item Group
Anesthesia Specific
Allergies
Item
Hypersensitivities
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
Are you allergic to adhesive tape?
Item
Are you allergic to adhesive tape?
boolean
Are you allergic to rubber products?
Item
Are you allergic to rubber products?
boolean
Previous Surgeries?
Item
Previous Surgeries?
string
Surgery involving an anesthetic?
Item
Surgery involving an anesthetic?
string
General Anesthesia
Item
General anaesthesia (GA)
boolean
C0002915 (UMLS CUI 2011AA)
50697003 (SNOMED CT 2011_0131)
10018060 (MedDRA 14.1)
Spinal Anesthesia
Item
Spinal Anaesthesia
boolean
C0002928 (UMLS CUI 2011AA)
231249005 (SNOMED CT 2011_0131)
10041536 (MedDRA 14.1)
Epidural anaesthesia
Item
epidural anesthesia
boolean
C0002913 (UMLS CUI 2011AA)
18946005 (SNOMED CT 2011_0131)
10015011 (MedDRA 14.1)
Regional anesthesia
Item
Regional Anesthesia Procedure
boolean
C0002911 (UMLS CUI 2011AA)
27372005 (SNOMED CT 2011_0131)
Local anesthesia
Item
Local anaesthesia (LA)
boolean
C0002921 (UMLS CUI 2011AA)
386761002 (SNOMED CT 2011_0131)
10024758 (MedDRA 14.1)
anesthetic: Moderate sedation
Item
anesthetic: Moderate sedation
boolean
anesthetic: Axillary block
Item
anesthetic: Axillary block
boolean
Have you or a family member ever had a problem with an anesthesic? If Yes, describe:
Item
Have you or a family member ever had a problem with an anesthesic? If Yes, describe:
string
Item Group
Health History - Endocrine
Diabetes
Item
Diabetes mellitus
boolean
C0011849 (UMLS CUI 2011AA)
191044006 (SNOMED CT 2011_0131)
If Diabetes, last time med taken
Item
If Diabetes, last time med taken
string
Hyperthyroidism
Item
Hyperthyroidism
boolean
C0020550 (UMLS CUI 2011AA)
34486009 (SNOMED CT 2011_0131)
10020850 (MedDRA 14.1)
MTHU020782 (LOINC Version 232)
E05.9 (ICD-10-CM Version 2010)
242.9 (ICD-9-CM Version 2011)
E10322 (CTCAE 1105E)
Hypothyroidism
Item
Hypothyroidism
boolean
C0020676 (UMLS CUI 2011AA)
40930008 (SNOMED CT 2011_0131)
10021114 (MedDRA 14.1)
MTHU020783 (LOINC Version 232)
E03.9 (ICD-10-CM Version 2010)
244.9 (ICD-9-CM Version 2011)
E10334 (CTCAE 1105E)
Item Group
Health History - Neurologic
CVA/Stroke/TIA
Item
Cerebrovascular accident (CVA)
string
C0038454 (UMLS CUI 2011AA)
230690007 (SNOMED CT 2011_0131)
10042244 (MedDRA 14.1)
I63.9 (ICD-10-CM Version 2010)
E12826 (CTCAE 1105E)
Seizures
Item
Convulsion
string
C0036572 (UMLS CUI 2011AA)
91175000 (SNOMED CT 2011_0131)
10039910 (MedDRA 14.1)
780.39 (ICD-9-CM Version 2011)
Numbness/Tingling to Arms/Legs
Item
Loss of Sensation
string
C0028643 (UMLS CUI 2011AA)
44077006 (SNOMED CT 2011_0131)
10029829 (MedDRA 14.1)
782.0 (ICD-9-CM Version 2011)
Migraines and/or Headaches
Item
Migraines and/or Headaches
string
C0149931, C0018681 (UMLS CUI 2011AA)
37796009, 25064002 (SNOMED CT 2011_0131)
10027599,1 (MedDRA 14.1)
MTHU020860 (LOINC Version 232)
G43, R51 (ICD-10-CM Version 2010)
346, 784.0 (ICD-9-CM Version 2011)
E12678 (CTCAE 1105E)
Blackout or Fainting Spells
Item
Blackout or Fainting Spells
string
C0312422 (UMLS CUI 2011AA)
418648005 (SNOMED CT 2011_0131)
10004982 (MedDRA 14.1)
R55 (ICD-10-CM Version 2010)
780.2 (ICD-9-CM Version 2011)
Item Group
Health History - Cardiovascular
Heart Attack/MI
Item
Heart Attack/MI
string
C0027051 (UMLS CUI 2011AA)
22298006 (SNOMED CT 2011_0131)
10028596 (MedDRA 14.1)
MTHU035551 (LOINC Version 232)
I21-I22 (ICD-10-CM Version 2010)
410 (ICD-9-CM Version 2011)
E10152 (CTCAE 1105E)
High Blood Pressure
Item
Hypertension
string
C0020538 (UMLS CUI 2011AA)
38341003 (SNOMED CT 2011_0131)
10020772 (MedDRA 14.1)
MTHU020789 (LOINC Version 232)
I10 (ICD-10-CM Version 2010)
997.91 (ICD-9-CM Version 2011)
E13785 (CTCAE 1105E)
Rapid Heart Rate
Item
Rapid heart beat, high heart frequency, heart rate increased
string
C0039231 (UMLS CUI 2011AA)
3424008 (SNOMED CT 2011_0131)
10019303 (MedDRA 14.1)
R00.0 (ICD-10-CM Version 2010)
785.0 (ICD-9-CM Version 2011)
Irregular Heart Beat
Item
Cardiac Arrhythmia
string
C0003811 (UMLS CUI 2011AA)
44808001 (SNOMED CT 2011_0131)
10003119 (MedDRA 14.1)
427.9 (ICD-9-CM Version 2011)
Cardiovascular Disease, Stents, Angioplasty, Heart Catherization
Item
Disease affecting entire cardiovascular system
string
C0007222 (UMLS CUI 2011AA)
105980002 (SNOMED CT 2011_0131)
10007649 (MedDRA 14.1)
429.2 (ICD-9-CM Version 2011)
Chest Pain/Angina
Item
Ischemic chest pain
string
C0002962 (UMLS CUI 2011AA)
194828000 (SNOMED CT 2011_0131)
10002383 (MedDRA 14.1)
I20 (ICD-10-CM Version 2010)
413 (ICD-9-CM Version 2011)
Item Group
Health History - Respiratory
Lung Disease
Item
Lung diseases
string
C0024115 (UMLS CUI 2011AA)
19829001 (SNOMED CT 2011_0131)
10025082 (MedDRA 14.1)
J98.4 (ICD-10-CM Version 2010)
Congestive Heart Failure
Item
Chronic congestive heart failure
string
C0264722 (UMLS CUI 2011AA)
42343007 (SNOMED CT 2011_0131)
10007559 (MedDRA 14.1)
MTHU020787 (LOINC Version 232)
I50 (ICD-10-CM Version 2010)
428 (ICD-9-CM Version 2011)
Chronic Cough
Item
Chronic cough
string
C0010201 (UMLS CUI 2011AA)
68154008 (SNOMED CT 2011_0131)
10066656 (MedDRA 14.1)
Asthma/Wheezing
Item
Asthma
string
C0004096 (UMLS CUI 2011AA)
195967001 (SNOMED CT 2011_0131)
10003553 (MedDRA 14.1)
MTHU020815 (LOINC Version 232)
J45 (ICD-10-CM Version 2010)
493 (ICD-9-CM Version 2011)
COPD/Bronchitis/Emphysema
Item
Chronic Obstructive Pulmonary Disease, Bronchial infection, Pulmonary Emphysema
string
C0024117, C0006277, C0034067 (UMLS CUI 2011AA)
13645005, 32398004, 87433001 (SNOMED CT 2011_0131)
10009033, 10006451, 10014561 (MedDRA 14.1)
J44.9, J40, J43 (ICD-10-CM Version 2010)
496, 490, 492 (ICD-9-CM Version 2011)
E11323 (CTCAE 1105E)
Pneumonia
Item
Pneumonitis
string
C0032285 (UMLS CUI 2011AA)
233604007 (SNOMED CT 2011_0131)
10035664 (MedDRA 14.1)
MTHU020831 (LOINC Version 232)
J18.9 (ICD-10-CM Version 2010)
E13502 (CTCAE 1105E)
Item Group
Health History - Genitourinary
Abnormal Kidney function
Item
Abnormal Kidney function
string
C1565489 (UMLS CUI 2011AA)
10038474 (MedDRA 14.1)
On Hemodialysis
Item
Haemodialysis
boolean
C0019004 (UMLS CUI 2011AA)
302497006 (SNOMED CT 2011_0131)
10018875 (MedDRA 14.1)
E71.43 (ICD-10-CM Version 2010)
39.95 (ICD-9-CM Version 2011)
On Peritoneal Dialysis
Item
Peritoneal Dialysis (PD)
boolean
C0031139 (UMLS CUI 2011AA)
71192002 (SNOMED CT 2011_0131)
10034660 (MedDRA 14.1)
54.98 (ICD-9-CM Version 2011)
Item Group
Health History - Gastrointestinal
Yellow Jaundice
Item
Icterus
string
C0022346 (UMLS CUI 2011AA)
18165001 (SNOMED CT 2011_0131)
10023126 (MedDRA 14.1)
R17 (ICD-10-CM Version 2010)
Hepatitis/Liver Disease
Item
Hepatitis
string
C0019158 (UMLS CUI 2011AA)
29001004 (SNOMED CT 2011_0131)
10019717 (MedDRA 14.1)
Freq. Indigestion/Reflux Disease
Item
gastric reflux
string
C0558176 (UMLS CUI 2011AA)
225587003 (SNOMED CT 2011_0131)
Gastric Ulcers
Item
Peptic Ulcer
string
C0030920 (UMLS CUI 2011AA)
13200003 (SNOMED CT 2011_0131)
10034341 (MedDRA 14.1)
K27 (ICD-10-CM Version 2010)
533 (ICD-9-CM Version 2011)
Item Group
Health History - Other
Bleed or Bruise Easily
Item
Bleeding diathesis
string
C1458140 (UMLS CUI 2011AA)
248250000 (SNOMED CT 2011_0131)
10005134 (MedDRA 14.1)
Blood Transfusions
Item
Transfusion
string
C1879316 (UMLS CUI 2011AA)
5447007 (SNOMED CT 2011_0131)
10066152 (MedDRA 14.1)
Cancer
Item
Malignant Neoplasms
string
C0006826 (UMLS CUI 2011AA)
363346000 (SNOMED CT 2011_0131)
10028997 (MedDRA 14.1)
MTHU010328 (LOINC Version 232)
C00-C96 (ICD-10-CM Version 2010)
Bleeding Disorders
Item
Bleeding Disorders
string
Obstructive Sleep Apnea
Item
SAS - Sleep apnea syndrome
string
C0037315 (UMLS CUI 2011AA)
73430006 (SNOMED CT 2011_0131)
10040979 (MedDRA 14.1)
G47.30 (ICD-10-CM Version 2010)
780.57 (ICD-9-CM Version 2011)
E13566 (CTCAE 1105E)
HAVE YOU HAD ANY MAJOR ILLNESS
Item
HAVE YOU HAD ANY MAJOR ILLNESS
string
DO YOU HAVE DENTURES
Item
DO YOU HAVE DENTURES
boolean
DO YOU HAVE BRIDGEWORK
Item
DO YOU HAVE BRIDGEWORK
boolean
DO YOU HAVE CAPPED TEETH
Item
DO YOU HAVE CAPPED TEETH
boolean
DO YOU HAVE LOOSE TEETH
Item
DO YOU HAVE LOOSE TEETH
boolean
Are you taking any medications NOW?
Item
Medication
string
C0013227 (UMLS CUI 2011AA)
Have you taken steroids in the last 6 months?
Item
Steroids
string
C0038317 (UMLS CUI 2011AA)
116566001 (SNOMED CT 2011_0131)
Item Group
Health History - Women's health
DATE OF LAST PERIOD
Item
DATE OF LAST PERIOD
date
Are pregnant?
Item
pregnant
boolean
C0549206 (UMLS CUI 2011AA)
10036586 (MedDRA 14.1)
Weeks Gestation
Item
Weeks Gestation
integer
EDC
Item
Estimated date of confinement (delivery date)
date
Item Group
Health History - Substance abuse and Smoking
Substance abuse
Item
Substance abuse problem
string
C0740858 (UMLS CUI 2011AA)
66214007 (SNOMED CT 2011_0131)
10066169 (MedDRA 14.1)
MTHU019364 (LOINC Version 232)
Do you currently smoke/use tobacco products?
Item
Smoker
boolean
CL025861 (UMLS CUI 2011AA)
What type of tobacco products?
Item
What type of tobacco products?
string
How much?
Item
How much?
string
Have you ever smoked /used tobacco products?
Item
Have you ever smoked /used tobacco products?
boolean
When did you quit?(If has used products in the past 12 months,MUST give smoking cessation advice/information)
Item
When did you quit?(If has used products in the past 12 months,MUST give smoking cessation advice/information)
date
What type of tobacco products?
Item
What type of tobacco products?
string
How much?
Item
How much?
string
Pediatric Smoking: Does anyone in your household currently use tobacco products?
Item
Pediatric Smoking: Does anyone in your household currently use tobacco products?
boolean
What type of tobacco products?
Item
What type of tobacco products?
string
How much?
Item
How much?
string
Has anyone in the house hold quit using tobacco products in the last 12 months?
Item
Has anyone in the house hold quit using tobacco products in the last 12 months?
boolean
When did the person in your house hold quit?(If has used products in the past 12 months, MUST give smoking cessation advice/information)
Item
When did the person in your house hold quit?(If has used products in the past 12 months, MUST give smoking cessation advice/information)
date
What type of tobacco products?
Item
What type of tobacco products?
string
How much?
Item
How much?
string
Tobacco/Smoking Cessation information/advice given to Patient
Item
Tobacco/Smoking Cessation information/advice given to Patient
boolean
Tobacco/Smoking Cessation information/advice given to Other
Item
Tobacco/Smoking Cessation information/advice given to Other
boolean
In what format was the smoking cessation given (Verbal, Handwritten, Pre-printed)?
Item
In what format was the smoking cessation given (Verbal, Handwritten, Pre-printed)?
integer
How much alcohol?
Item
How much alcohol?
string
How often alcohol?
Item
How often alcohol?
string
RECREATIONAL DRUGS
Item
RECREATIONAL DRUGS
string
Item Group
Immunizations
Immunizations
Item
Immunisation
string
C0020971 (UMLS CUI 2011AA)
127785005 (SNOMED CT 2011_0131)
10021431 (MedDRA 14.1)
IMMUNIZ (HL7 V3 2006_05)
Item Group
SPECIALTY CLINIC specific
SPECIALTY CLINIC specific
Item
SPECIALTY CLINIC specific
string
Item Group
Nutrition
Current Weight
Item
Current Weight
integer
Have you experienced any unexplained weight loss or gain in the past 6 months?
Item
Have you experienced any unexplained weight loss or gain in the past 6 months?
boolean
As compared to normal, would you rate your food intake during the past month as either: CHANGED- MORE- LESS
Item
As compared to normal, would you rate your food intake during the past month as either: CHANGED- MORE- LESS
integer
Item Group
Assistance / Mobility
Do you live alone?
Item
Do you live alone?
boolean
Does anyone assist you at home?
Item
Needs assistance at home
boolean
C0578564 (UMLS CUI 2011AA)
301887005 (SNOMED CT 2011_0131)
If yes, Name and phone number of person and/or facility that assists
Item
If yes, Name and phone number of person and/or facility that assists
string
Equipment needed for WOUND(S)
Item
Equipment needed for WOUND(S)
string
Where is your wound(s) located?
Item
Wound
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
How long have you had the wound(s)?
Item
How long have you had the wound(s)?
date
How did the wounds start?
Item
How did the wounds start?
string
How have you been treating the wound(s)?
Item
How have you been treating the wound(s)?
string

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