CDE Detailed Report
Disease: cookie-policy
Sub-Domain: Participant History and Family History
CRF:

Displaying 1 - 50 of 82
CDE ID CDE Name Variable Name Definition Short Description Additional Notes (Question Text) Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type Source Form Set Form Field
C19806 Medical history endocrine diabetes indicator MedHistEndcrnDiabetInd Indicator of diabetes Indicator of diabetes Ever have diabetes? No;Yes No;Yes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19838 Pain position text PainPosTxt The free-text field related to 'Pain Position indicator' Indicator of pain within a certain position of the body The free-text field related to 'Pain Position indicator' Indicator of pain within a certain position of the body If Yes, specify Alphanumeric

Only answered if Pain question #2 is answered Yes.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19774 Medical history snoring presence indicator MedHistPlmnrySnorePresInd Indicator of snoring Indicator of snoring Any snoring? No;Yes No;Yes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19817 Medical history musculoskeletal total broken bones mechanism type MedHistMusclBrknBonMechTyp Type of mechanism broken Type of mechanism broken If Yes, specify bones broken and mechanism broken: Alphanumeric

Answer for all applicable broken bones

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History 255

Free-Form Entry

C19785 Medical history pulmonary bilevel positive airway pressure start date MedHistLabPrPlBiPAPStrtDt Date of start of bilevel positive airway pressure Date of start of bilevel positive airway pressure If Yes, when started Date or Date & Time

The date should be recorded in the format YYYY/MM, and only answered if Pulmonary question #1 is answered Yes.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19828 Learning disability mental retardation indicator NeuroLearnDisabMentlRetrdnInd Indicator of mental retardation Indicator of mental retardation If Yes, is the learning disability characterized as mental retardation (IQ <70) either through formal IQ testing or exam? No;Yes;Unknown No;Yes;Unknown Alphanumeric

Only answered if question #3 under neurologic is answered Yes

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19764 Medical history retinal detachment diagnosis indicator MedHistRetnlDetachDiagInd Indicator of history of retinal detachment Indicator of history of retinal detachment Retinal detachment No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19796 Medical history cardiovascular enlarged heart diagnosis method type MedHistCardioEnlHeDiagMetTyp Indicator of enlarged heart detection method Indicator of enlarged heart detection method If Yes, how detected: Chest X-ray;Echocardiogram Chest X-ray;Echocardiogram Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19807 Medical history abdominal difficulty eating indicator MedHistAbdmnlDfcltyEatingInd Indicator of history of difficulty eating Indicator of history of difficulty eating History of difficulty eating? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19839 Pain exersice indicator PainExrcseInd Indicator of pain while excercising Indicator of pain while excercising Pain with exercise? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19775 Medical history sleep pulmonary assessment indicator MedHistSleepPulAssessInd Indicator of sleep study completed Indicator of sleep study completed Any sleep study done? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19818 Medical history musculoskeletal total broken bones trauma type MedHistMusclBrknBonTraumaTyp Type of broken bone trauma Type of broken bone trauma If Yes, specify bones broken and mechanism broken: Major trauma;Minor trauma (slip and fall) Major trauma;Minor trauma (slip and fall) Alphanumeric

Answer for all applicable broken bones

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Multiple Pre-Defined Values Selected

C19786 Medical history pulmonary bilevel positive airway pressure hospitalization indicator MedHistPlmnryBiPAPHosptlInd Indicator of bilevel positive airway pressure hospitilization Indicator of bilevel positive airway pressure hospitilization BiPAP only with hospitalization or illness: No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19829 Behavioral issues indicator BehavrIssuesInd Indicator of behavioral issues Indicator of behavioral issues Behavioral issues? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19765 Medical history auditory deafness diagnosis indicator MedHistAudtryDeafDiagInd Indicator of any history of deafness Indicator of any history of deafness Any history of deafness? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19797 Medical history endocrine early puberty indicator MedHistEndcrnErlyPubrtyInd Indicator of history of early puberty Indicator of history of early puberty Any history of early puberty? No;Yes No;Yes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19808 Medical history abdominal difficulty swallowing indicator MedHistAbdmnlDfclSwallInd Indicator of history of difficulty swallowing Indicator of history of difficulty swallowing History of difficulty swallowing? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19776 Medical history sleep pulmonary assessment date MedHistSleepPulAssessDate Date of sleep study completed Date of sleep study completed If Yes, date sleep study done Date or Date & Time

The date should be recorded in the format YYYY/MM.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19819 Medical history musculoskeletal joint dislocation indicator MedHistMusclJointDislocInd Indicator of joint dislocation Indicator of joint dislocation Joint dislocation? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19787 Medical history pulmonary ventilator use indicator MedHistPlmnryVentltrUseInd Indicator of ventilator used Indicator of ventilator used Ventilator: No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19830 Behavioral issues onset date BehavrIssuesOnstDate Date of onset of behavioral issues Date of onset of behavioral issues If Yes, date of onset Date or Date & Time

The date should be recorded in the format YYYY/MM, and only answered if Neurologic question #5 is answered Yes.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19766 Medical history auditory deafness diagnosis date MedHistAudtryDeafDiagDate Date deafness first detected Date deafness first detected If Yes, date first detected: Date or Date & Time

The date should be recorded in the format YYYY/MM.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19798 Medical history endocrine male indicator MedHistEndcrnMaleInd Text of age of breast bud formation detected Text of age of breast bud formation detected If participant/subject is male, check N/A Alphanumeric

If pariticpant/subject is male, check N/A

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19809 Medical history abdominal constipation indicator MedHistAbdmnlConstptnInd Indicator of history of constipation Indicator of history of constipation History of constipation? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19777 Medical history wheezing pulmonary assessment indicator MedHistWheezPulAssessInd Indicator of wheezing Indicator of wheezing Wheezing? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19820 Medical history musculoskeletal total joint dislocations count MedHistMusclTtlJointDislocCt Number of total joints dislocated Number of total joints dislocated If Yes, total number of joint dislocations: Numeric Values

Only answered if Musculoskeletal question # 2 is answered Yes.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19788 Medical history pulmonary ventilator use frequency MedHistPlmnryVentltrUseFreq Frequency of use of ventilator Frequency of use of ventilator If Yes, how many hours a day? Numeric Values

The answer should be recorded as the number of hours per day.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19831 Psychiatric anxiety indicator PsychAnxInd Indicator of anxiety Indicator of anxiety Anxiety: No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19767 Medical history pulmonary difficulty diagnosis indicator MedHistoryPlmnryDfltcyDiagInd Indicator of difficulty breathing Indicator of difficulty breathing Any difficulty breathing? Yes;No;Sometimes Yes;No;Sometimes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19799 Medical history endocrine breast bud formation age value MedHistEndcrnBrBudFormAgeVal Text of age of breast bud formation detected Text of age of breast bud formation detected If female, at what age did you notice breast bud formation? Numeric Values

Only to be answered if participant/subject is female.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19810 Medical history abdominal kidney problem indicator MedHistAbdmnlKdnyProbInd Indicator of history of kidney problem Indicator of history of kidney problem Ever have a kidney problem? No;Yes No;Yes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

DeBaun Forms
C19778 Medical history wheezing pulmonary nebulizer use frequency MedHistWheezPulNebulUseFreq Frequency of nebulizer use in relation to wheezing Frequency of nebulizer use in relation to wheezing If Yes, how often do you use nebulizer? Numeric Values

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19821 Medical history musculoskeletal joint dislocation type MedHistMusclskltlJointDislocTyp Type of joints dislcoated Type of joints dislcoated If Yes, specify joints dislocated and mechanism Elbow;Patella (knee cap);Wrist;Shoulder Elbow;Patella (knee cap);Wrist;Shoulder Alphanumeric

Choose all that apply

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Multiple Pre-Defined Values Selected

C19789 Medical history pulmonary cough assist status MedHistPlmnryCghAstStatus Status of cough assist Status of cough assist Mechanical In/Ex-sufflation (cough assist): Daily;Only when ill;Don't use;Unknown Daily;Only when ill;Don't use;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19832 Psychiatric anxiety onset date PsychAnxOnstDate Date of onset of anxiety Date of onset of anxiety If Yes, date of onset Date or Date & Time

The date should be recorded in the format YYYY/MM, and only answered if Psychiatric question #1 is answered Yes.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19768 Medical history pulmonary difficulty ingestion relatedness indicator MedHistPlDfltcyIngesRltdnsInd Indicator of difficulty breathing relation to meal times Indicator of difficulty breathing relation to meal times If Yes, is difficulty breathing related to meal times? No;Yes;Unknown No;Yes;Unknown Alphanumeric

Only answered if Pulmonary question #1 is answered Yes

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19800 Medical history endocrine menarche indicator MedHistEndcrnMenarcheInd Indicator of start of menarche Indicator of start of menarche If female, start of her period (menarche)? No;Yes;Unknown No;Yes;Unknown Alphanumeric

Only to be answered if participant/subject is female.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19811 Medical history abdominal liver problem indicator MedHistAbdmnlLiverProbInd Indicator of history of liver problem Indicator of history of liver problem Ever have a liver problem? No;Yes No;Yes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

DeBaun Forms
C19779 Medical history asthma pulmonary assessment indicator MedHistAsthmaPulAssesInd Indicator of history of asthma Indicator of history of asthma History of asthma? No;Yes No;Yes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

DeBaun Forms
C19822 Medical history musculoskeletal joint dislocation mechanism type MedHistMusclJointDislmechTyp Type of joints and mechanism dislocated Type of joints and mechanism dislocated If Yes, specify joints dislocated and mechanism Alphanumeric

Answer for all applicable joints dislocated

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C05460 Seizure indicator SeizInd Indicator of seizure activity Indicator of seizure activity Seizure Yes;No Yes;No Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 3.00 2013-07-20 10:21:25.65 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19790 Medical history pulmonary current intermittent positive pressure breathing use status MedHistPlCrntIPPBUseStatus Status of current Intermittent Positive Pressure Breathing (IPPB) use Status of current Intermittent Positive Pressure Breathing (IPPB) use Are you currently using IPPB?: Daily;Only when ill;Don't use;Unknown Daily;Only when ill;Don't use;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19833 Psychiatric depression indicator PsychDepressInd Indicator of history of depression Indicator of history of depression Depression: No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19769 Medical history pulmonary aspiration diagnosis indicator MedHistPlmnryAspirDiagInd Indicator of history of aspiration Indicator of history of aspiration History of aspiration? No;Yes;Unknown No;Yes;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19801 Medical history endocrine menarche onset date MedHistEndcrnMenarcheOnstDate Date of start of onset of menarche Date of start of onset of menarche If Yes, date of onset Date or Date & Time

The date should be recorded in the format YYYY/MM and only answered if Endocrine question #3 is answered Yes.

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Free-Form Entry

C19812 Medical history abdominal liver problem enzyme elevation indicator MedHistAbdmnlLivProbEnzElInd Indicator of elevation in liver enzyme Indicator of elevation in liver enzyme If Yes, was this an elevation in the liver enzyme (AST/ALT) only? No;Yes No;Yes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19780 Medical history asthma pulmonary medication taken indicator MedHistAsthmaPulMedsTakenInd Indicator of steroid pills or liquid medication taken for asthma Indicator of steroid pills or liquid medication taken for asthma If Yes, steroid pills or liquid medication for asthma? No;Yes No;Yes Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19823 Medical history musculoskeletal joint dislocation trauma type MedHistMusclskltlJointDislocTaumaTyp Type of joint dislocation trauma Type of joint dislocation trauma If Yes, specify joints dislocated and mechanism Major trauma;Minor trauma (slip and fall) Major trauma;Minor trauma (slip and fall) Alphanumeric

Answer for all applicable joints dislocated

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C14116 Learning disability or attention deficit diagnosis indicator LearnDisableADHDDiagnosInd Whether the participant/subject was ever given formal diagnosis of any learning disability or diagnosed with ADD/ADHD (Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder) Whether the participant/subject was formally diagnosed with learning disability, attention deficit disorder, or attention deficit hyperactivity disorder. Is there a learning disability? Yes;No;Unknown Yes;No;Unknown Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 3.00 2013-08-28 16:08:00.453 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

C19791 Medical history pulmonary antibiotics use frequency MedHistPlmnryAntibiotUseFreq Frequency of antibiotic use Frequency of antibiotic use How many times have you required antibiotics for a cold or pneumonia in the last year? None;Once;2 times;3 times;4 times;<5 times None;Once;2 times;3 times;4 times;<5 times Alphanumeric

No instructions available

No references available Adult;Pediatric Proposed 1.00 2015-02-05 00:00:00.0 Intake Medical History Participant History and Family History General Health History

Single Pre-Defined Value Selected

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