ID

5582

Beschrijving

Form from HIS OpenVistA

Trefwoorden

Versies (4)
  1. 18-02-12 18-02-12 -
  2. 07-08-14 07-08-14 - Martin Dugas
  3. 09-08-14 09-08-14 - Martin Dugas
  4. 26-06-15 26-06-15 - Martin Dugas
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9 augustus 2014

DOI

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Creative Commons BY-NC 3.0 Legacy
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HIS HEALTH HISTORY I_ANESTHESIA MULTIDISCIPLINARY

Duits Engels

HIS

1 Formulieren  
  1. StudyEvent: HIS
    1. HIS
Overview
Beschrijving

Overview

Alter
Beschrijving

Age

Datatype

string

Alias
UMLS CUI 2011AA
C0001779
SNOMED CT 2011_0131
397669002
Größe
Beschrijving

Height

Datatype

string

Alias
UMLS CUI-1
C0005890
LOINC Version 232
MTHU005354
Gewicht
Beschrijving

Weight

Datatype

string

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

Temperature

Datatype

string

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
Pulsfrequenz
Beschrijving

Pulse Rate

Datatype

string

Alias
UMLS CUI 2011AA
C0232117
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
Atemfrequenz
Beschrijving

Respiratory rate

Datatype

string

Alias
UMLS CUI 2011AA
C0231832
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
Blutdruck
Beschrijving

Blood Pressure

Datatype

string

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

PT'S RESIDENCE

Datatype

string

LANGUAGE/COMMUNICATION BARRIER
Beschrijving

LANGUAGE/COMMUNICATION BARRIER

Datatype

string

PRIMARY LANGUAGE
Beschrijving

PRIMARY LANGUAGE

Datatype

string

Hauptbeschwerden
Beschrijving

CHIEF COMPLAINT

Datatype

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
Hausarzt
Beschrijving

Primary Care Physician (PCP)

Datatype

string

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

Anesthesia Specific

Allergien
Beschrijving

Allergies

Datatype

string

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

Are you allergic to adhesive tape?

Datatype

boolean

Are you allergic to rubber products?
Beschrijving

Are you allergic to rubber products?

Datatype

boolean

Previous Surgeries?
Beschrijving

Previous Surgeries?

Datatype

string

Surgery involving an anesthetic?
Beschrijving

Surgery involving an anesthetic?

Datatype

string

Allgemeinanästhesie
Beschrijving

General Anesthesia

Datatype

boolean

Alias
UMLS CUI 2011AA
C0002915
SNOMED CT 2011_0131
50697003
MedDRA 14.1
10018060
Spinalanästhesie
Beschrijving

Spinal Anesthesia

Datatype

boolean

Alias
UMLS CUI 2011AA
C0002928
SNOMED CT 2011_0131
231249005
MedDRA 14.1
10041536
Epiduralanästhesie
Beschrijving

Epidural anaesthesia

Datatype

boolean

Alias
UMLS CUI 2011AA
C0002913
SNOMED CT 2011_0131
18946005
MedDRA 14.1
10015011
Regionalanästhesie
Beschrijving

Regional anesthesia

Datatype

boolean

Alias
UMLS CUI 2011AA
C0002911
SNOMED CT 2011_0131
27372005
Lokalanästhesie
Beschrijving

Local anesthesia

Datatype

boolean

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

anesthetic: Moderate sedation

Datatype

boolean

anesthetic: Axillary block
Beschrijving

anesthetic: Axillary block

Datatype

boolean

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

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

Datatype

string

Health History - Endocrine
Beschrijving

Health History - Endocrine

Diabetes mellitus
Beschrijving

Diabetes

Datatype

boolean

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

If Diabetes, last time med taken

Datatype

string

Hyperthyreose
Beschrijving

Hyperthyroidism

Datatype

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
Hypothyreose
Beschrijving

Hypothyroidism

Datatype

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
Beschrijving

Health History - Neurologic

Schlaganfall
Beschrijving

CVA/Stroke/TIA

Datatype

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
Krampfanfall
Beschrijving

Seizures

Datatype

string

Alias
UMLS CUI 2011AA
C0036572
SNOMED CT 2011_0131
91175000
MedDRA 14.1
10039910
ICD-9-CM Version 2011
780.39
Taubheitsgefühl
Beschrijving

Numbness/Tingling to Arms/Legs

Datatype

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
Beschrijving

Migraines and/or Headaches

Datatype

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
Beschrijving

Blackout or Fainting Spells

Datatype

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
Beschrijving

Health History - Cardiovascular

Heart Attack/MI
Beschrijving

Heart Attack/MI

Datatype

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
Hypertonie
Beschrijving

High Blood Pressure

Datatype

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
Tachykardie
Beschrijving

Rapid Heart Rate

Datatype

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
Herzrhythmusstörung
Beschrijving

Irregular Heart Beat

Datatype

string

Alias
UMLS CUI 2011AA
C0003811
SNOMED CT 2011_0131
44808001
MedDRA 14.1
10003119
ICD-9-CM Version 2011
427.9
Kardiovaskuläre Erkrankung
Beschrijving

Cardiovascular Disease, Stents, Angioplasty, Heart Catherization

Datatype

string

Alias
UMLS CUI 2011AA
C0007222
SNOMED CT 2011_0131
105980002
MedDRA 14.1
10007649
ICD-9-CM Version 2011
429.2
Angina Pectoris
Beschrijving

Chest Pain/Angina

Datatype

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
Beschrijving

Health History - Respiratory

Lungenerkrankung
Beschrijving

Lung Disease

Datatype

string

Alias
UMLS CUI 2011AA
C0024115
SNOMED CT 2011_0131
19829001
MedDRA 14.1
10025082
ICD-10-CM Version 2010
J98.4
Herzinsuffizienz
Beschrijving

Congestive Heart Failure

Datatype

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
Chronischer Husten
Beschrijving

Chronic Cough

Datatype

string

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

Asthma/Wheezing

Datatype

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
COPD, Bronchitis, Lungenemphysem
Beschrijving

COPD/Bronchitis/Emphysema

Datatype

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
Pneumonie
Beschrijving

Pneumonia

Datatype

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
Beschrijving

Health History - Genitourinary

Abnormal Kidney function
Beschrijving

Abnormal Kidney function

Datatype

string

Alias
UMLS CUI 2011AA
C1565489
MedDRA 14.1
10038474
Hämodialyse
Beschrijving

On Hemodialysis

Datatype

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
Peritonealdialyse
Beschrijving

On Peritoneal Dialysis

Datatype

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
Beschrijving

Health History - Gastrointestinal

Ikterus
Beschrijving

Yellow Jaundice

Datatype

string

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

Hepatitis/Liver Disease

Datatype

string

Alias
UMLS CUI 2011AA
C0019158
SNOMED CT 2011_0131
29001004
MedDRA 14.1
10019717
Gastroösophagealer Reflux
Beschrijving

Freq. Indigestion/Reflux Disease

Datatype

string

Alias
UMLS CUI 2011AA
C0558176
SNOMED CT 2011_0131
225587003
Gastroduodenales Ulkus
Beschrijving

Gastric Ulcers

Datatype

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
Beschrijving

Health History - Other

Blutungsneigung
Beschrijving

Bleed or Bruise Easily

Datatype

string

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

Blood Transfusions

Datatype

string

Alias
UMLS CUI 2011AA
C1879316
SNOMED CT 2011_0131
5447007
MedDRA 14.1
10066152
Krebs
Beschrijving

Cancer

Datatype

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
Beschrijving

Bleeding Disorders

Datatype

string

SAS - Sleep apnea syndrome
Beschrijving

Obstructive Sleep Apnea

Datatype

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
Beschrijving

HAVE YOU HAD ANY MAJOR ILLNESS

Datatype

string

DO YOU HAVE DENTURES
Beschrijving

DO YOU HAVE DENTURES

Datatype

boolean

DO YOU HAVE BRIDGEWORK
Beschrijving

DO YOU HAVE BRIDGEWORK

Datatype

boolean

DO YOU HAVE CAPPED TEETH
Beschrijving

DO YOU HAVE CAPPED TEETH

Datatype

boolean

DO YOU HAVE LOOSE TEETH
Beschrijving

DO YOU HAVE LOOSE TEETH

Datatype

boolean

Medikation
Beschrijving

Are you taking any medications NOW?

Datatype

string

Alias
UMLS CUI 2011AA
C0013227
Steroide
Beschrijving

Have you taken steroids in the last 6 months?

Datatype

string

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

Health History - Women's health

DATE OF LAST PERIOD
Beschrijving

DATE OF LAST PERIOD

Datatype

date

schwanger
Beschrijving

Are pregnant?

Datatype

boolean

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

Weeks Gestation

Datatype

integer

Estimated date of confinement (delivery date)
Beschrijving

EDC

Datatype

date

Health History - Substance abuse and Smoking
Beschrijving

Health History - Substance abuse and Smoking

Drogenmissbrauch
Beschrijving

Substance abuse

Datatype

string

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

Do you currently smoke/use tobacco products?

Datatype

boolean

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

What type of tobacco products?

Datatype

string

How much?
Beschrijving

How much?

Datatype

string

Have you ever smoked /used tobacco products?
Beschrijving

Have you ever smoked /used tobacco products?

Datatype

boolean

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

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

Datatype

date

What type of tobacco products?
Beschrijving

What type of tobacco products?

Datatype

string

How much?
Beschrijving

How much?

Datatype

string

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

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

Datatype

boolean

What type of tobacco products?
Beschrijving

What type of tobacco products?

Datatype

string

How much?
Beschrijving

How much?

Datatype

string

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

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

Datatype

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)
Beschrijving

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

Datatype

date

What type of tobacco products?
Beschrijving

What type of tobacco products?

Datatype

string

How much?
Beschrijving

How much?

Datatype

string

Tobacco/Smoking Cessation information/advice given to Patient
Beschrijving

Tobacco/Smoking Cessation information/advice given to Patient

Datatype

boolean

Tobacco/Smoking Cessation information/advice given to Other
Beschrijving

Tobacco/Smoking Cessation information/advice given to Other

Datatype

boolean

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

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

Datatype

integer

How much alcohol?
Beschrijving

How much alcohol?

Datatype

string

How often alcohol?
Beschrijving

How often alcohol?

Datatype

string

RECREATIONAL DRUGS
Beschrijving

RECREATIONAL DRUGS

Datatype

string

Immunizations
Beschrijving

Immunizations

Impfung
Beschrijving

Immunizations

Datatype

string

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

SPECIALTY CLINIC specific

SPECIALTY CLINIC specific
Beschrijving

SPECIALTY CLINIC specific

Datatype

string

Nutrition
Beschrijving

Nutrition

Current Weight
Beschrijving

Current Weight

Datatype

integer

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

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

Datatype

boolean

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

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

Datatype

integer

Assistance / Mobility
Beschrijving

Assistance / Mobility

Do you live alone?
Beschrijving

Do you live alone?

Datatype

boolean

Benötigt Unterstützung zuhause
Beschrijving

Does anyone assist you at home?

Datatype

boolean

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

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

Datatype

string

Equipment needed for WOUND(S)
Beschrijving

Equipment needed for WOUND(S)

Datatype

string

Wunde
Beschrijving

Where is your wound(s) located?

Datatype

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)?
Beschrijving

How long have you had the wound(s)?

Datatype

date

How did the wounds start?
Beschrijving

How did the wounds start?

Datatype

string

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

How have you been treating the wound(s)?

Datatype

string

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Similar models

HIS

1 Formulieren
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Age
Item
Alter
string
C0001779 (UMLS CUI 2011AA)
397669002 (SNOMED CT 2011_0131)
Height
Item
Größe
string
C0005890 (UMLS CUI-1)
MTHU005354 (LOINC Version 232)
Weight
Item
Gewicht
string
C0005910 (UMLS)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
Temperature
Item
Temperatur
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
Pulse Rate
Item
Pulsfrequenz
string
C0232117 (UMLS CUI 2011AA)
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
Respiratory rate
Item
Atemfrequenz
string
C0231832 (UMLS CUI 2011AA)
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
Blood Pressure
Item
Blutdruck
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
Hauptbeschwerden
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
Primary Care Physician (PCP)
Item
Hausarzt
string
C0033131, C0017319 (UMLS CUI 2011AA)
446050000, 59058001 (SNOMED CT 2011_0131)
PCP (HL7 V3 2006_05)
Allergies
Item
Allergien
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
Allgemeinanästhesie
boolean
C0002915 (UMLS CUI 2011AA)
50697003 (SNOMED CT 2011_0131)
10018060 (MedDRA 14.1)
Spinal Anesthesia
Item
Spinalanästhesie
boolean
C0002928 (UMLS CUI 2011AA)
231249005 (SNOMED CT 2011_0131)
10041536 (MedDRA 14.1)
Epidural anaesthesia
Item
Epiduralanästhesie
boolean
C0002913 (UMLS CUI 2011AA)
18946005 (SNOMED CT 2011_0131)
10015011 (MedDRA 14.1)
Regional anesthesia
Item
Regionalanästhesie
boolean
C0002911 (UMLS CUI 2011AA)
27372005 (SNOMED CT 2011_0131)
Local anesthesia
Item
Lokalanästhesie
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
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
Hyperthyreose
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
Hypothyreose
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)
CVA/Stroke/TIA
Item
Schlaganfall
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
Krampfanfall
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
Taubheitsgefühl
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)
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
Hypertonie
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
Tachykardie
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
Herzrhythmusstörung
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
Kardiovaskuläre Erkrankung
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
Angina Pectoris
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)
Lung Disease
Item
Lungenerkrankung
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
Herzinsuffizienz
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
Chronischer Husten
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
COPD, Bronchitis, Lungenemphysem
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
Pneumonie
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)
Abnormal Kidney function
Item
Abnormal Kidney function
string
C1565489 (UMLS CUI 2011AA)
10038474 (MedDRA 14.1)
On Hemodialysis
Item
Hämodialyse
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
Peritonealdialyse
boolean
C0031139 (UMLS CUI 2011AA)
71192002 (SNOMED CT 2011_0131)
10034660 (MedDRA 14.1)
54.98 (ICD-9-CM Version 2011)
Yellow Jaundice
Item
Ikterus
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
Gastroösophagealer Reflux
string
C0558176 (UMLS CUI 2011AA)
225587003 (SNOMED CT 2011_0131)
Gastric Ulcers
Item
Gastroduodenales Ulkus
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)
Bleed or Bruise Easily
Item
Blutungsneigung
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
Krebs
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
Medikation
string
C0013227 (UMLS CUI 2011AA)
Have you taken steroids in the last 6 months?
Item
Steroide
string
C0038317 (UMLS CUI 2011AA)
116566001 (SNOMED CT 2011_0131)
DATE OF LAST PERIOD
Item
DATE OF LAST PERIOD
date
Are pregnant?
Item
schwanger
boolean
C0549206 (UMLS CUI 2011AA)
10036586 (MedDRA 14.1)
Weeks Gestation
Item
Weeks Gestation
integer
EDC
Item
Estimated date of confinement (delivery date)
date
Substance abuse
Item
Drogenmissbrauch
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
Raucher
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
Item
Impfung
string
C0020971 (UMLS CUI 2011AA)
127785005 (SNOMED CT 2011_0131)
10021431 (MedDRA 14.1)
IMMUNIZ (HL7 V3 2006_05)
SPECIALTY CLINIC specific
Item
SPECIALTY CLINIC specific
string
Item Group
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
Do you live alone?
Item
Do you live alone?
boolean
Does anyone assist you at home?
Item
Benötigt Unterstützung zuhause
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
Wunde
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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