ID

11251

Descripción

Form from HIS OpenVistA

Palabras clave

Versiones (4)
  1. 18/2/12 18/2/12 -
  2. 7/8/14 7/8/14 - Martin Dugas
  3. 9/8/14 9/8/14 - Martin Dugas
  4. 26/6/15 26/6/15 - Martin Dugas
Subido en

26 de junio de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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HEALTH HISTORY I_ANESTHESIA MULTIDISCIPLINARY

Alemán Inglés

HIS

1 formularios  
  1. StudyEvent: HIS
    1. HIS
Overview
Descripción

Overview

Alter
Descripción

Age

Tipo de datos

integer

Unidades de medida
  • years
Alias
SNOMED CT 2011_0131
397669002
UMLS CUI-1
C0001779
years
Größe
Descripción

Height

Tipo de datos

float

Unidades de medida
  • cm
Alias
LOINC Version 232
MTHU005354
UMLS CUI-1
C0005890
cm
Gewicht
Descripción

Weight

Tipo de datos

float

Unidades de medida
  • kg
Alias
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
UMLS CUI-1
C0005910
kg
Temperatur
Descripción

Temperature

Tipo de datos

float

Unidades de medida
  • °C
Alias
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
UMLS CUI-1
C0039476
°C
Pulsfrequenz
Descripción

Pulse Rate

Tipo de datos

integer

Unidades de medida
  • beats/min
Alias
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
UMLS CUI-1
C0232117
beats/min
Atemfrequenz
Descripción

Respiratory rate

Tipo de datos

integer

Alias
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
UMLS CUI-1
C0231832
Blutdruck
Descripción

Blood Pressure

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
UMLS CUI-1
C0005823
mmHg
PT'S RESIDENCE
Descripción

PT'S RESIDENCE

Tipo de datos

string

LANGUAGE/COMMUNICATION BARRIER
Descripción

LANGUAGE/COMMUNICATION BARRIER

Tipo de datos

string

PRIMARY LANGUAGE
Descripción

PRIMARY LANGUAGE

Tipo de datos

string

Hauptbeschwerden
Descripción

CHIEF COMPLAINT

Tipo de datos

string

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

Primary Care Physician (PCP)

Tipo de datos

text

Alias
SNOMED CT 2011_0131
446050000, 59058001
HL7 V3 2006_05
PCP
UMLS CUI-1
C0033131
UMLS CUI-2
C0017319
Anesthesia Specific
Descripción

Anesthesia Specific

Allergien
Descripción

Allergies

Tipo de datos

string

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

Are you allergic to adhesive tape?

Tipo de datos

boolean

Are you allergic to rubber products?
Descripción

Are you allergic to rubber products?

Tipo de datos

boolean

Previous Surgeries?
Descripción

Previous Surgeries?

Tipo de datos

string

Surgery involving an anesthetic?
Descripción

Surgery involving an anesthetic?

Tipo de datos

string

Allgemeinanästhesie
Descripción

General Anesthesia

Tipo de datos

boolean

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

Spinal Anesthesia

Tipo de datos

boolean

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

Epidural anaesthesia

Tipo de datos

boolean

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

Regional anesthesia

Tipo de datos

boolean

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

Local anesthesia

Tipo de datos

boolean

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

anesthetic: Moderate sedation

Tipo de datos

boolean

anesthetic: Axillary block
Descripción

anesthetic: Axillary block

Tipo de datos

boolean

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

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

Tipo de datos

string

Health History - Endocrine
Descripción

Health History - Endocrine

Diabetes mellitus
Descripción

Diabetes

Tipo de datos

boolean

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

If Diabetes, last time med taken

Tipo de datos

string

Hyperthyreose
Descripción

Hyperthyroidism

Tipo de datos

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
Descripción

Hypothyroidism

Tipo de datos

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
Descripción

Health History - Neurologic

Schlaganfall
Descripción

CVA/Stroke/TIA

Tipo de datos

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
Descripción

Seizures

Tipo de datos

string

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

Numbness/Tingling to Arms/Legs

Tipo de datos

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
Descripción

Migraines and/or Headaches

Tipo de datos

text

Alias
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
UMLS CUI-1
C0149931
UMLS CUI-2
C0018681
Blackout or Fainting Spells
Descripción

Blackout or Fainting Spells

Tipo de datos

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
Descripción

Health History - Cardiovascular

Heart Attack/MI
Descripción

Heart Attack/MI

Tipo de datos

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
Descripción

High Blood Pressure

Tipo de datos

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
Descripción

Rapid Heart Rate

Tipo de datos

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
Descripción

Irregular Heart Beat

Tipo de datos

string

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

Cardiovascular Disease, Stents, Angioplasty, Heart Catherization

Tipo de datos

string

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

Chest Pain/Angina

Tipo de datos

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
Descripción

Health History - Respiratory

Lungenerkrankung
Descripción

Lung Disease

Tipo de datos

string

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

Congestive Heart Failure

Tipo de datos

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
Descripción

Chronic Cough

Tipo de datos

string

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

Asthma/Wheezing

Tipo de datos

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
Descripción

COPD/Bronchitis/Emphysema

Tipo de datos

text

Alias
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
UMLS CUI-1
C0024117
UMLS CUI-2
C0006277
UMLS CUI-3
C0034067
Pneumonie
Descripción

Pneumonia

Tipo de datos

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
Descripción

Health History - Genitourinary

Abnormal Kidney function
Descripción

Abnormal Kidney function

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1565489
MedDRA 14.1
10038474
Hämodialyse
Descripción

On Hemodialysis

Tipo de datos

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
Descripción

On Peritoneal Dialysis

Tipo de datos

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
Descripción

Health History - Gastrointestinal

Ikterus
Descripción

Yellow Jaundice

Tipo de datos

string

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

Hepatitis/Liver Disease

Tipo de datos

string

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

Freq. Indigestion/Reflux Disease

Tipo de datos

string

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

Gastric Ulcers

Tipo de datos

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
Descripción

Health History - Other

Blutungsneigung
Descripción

Bleed or Bruise Easily

Tipo de datos

string

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

Blood Transfusions

Tipo de datos

string

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

Cancer

Tipo de datos

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
Descripción

Bleeding Disorders

Tipo de datos

string

SAS - Sleep apnea syndrome
Descripción

Obstructive Sleep Apnea

Tipo de datos

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
Descripción

HAVE YOU HAD ANY MAJOR ILLNESS

Tipo de datos

string

DO YOU HAVE DENTURES
Descripción

DO YOU HAVE DENTURES

Tipo de datos

boolean

DO YOU HAVE BRIDGEWORK
Descripción

DO YOU HAVE BRIDGEWORK

Tipo de datos

boolean

DO YOU HAVE CAPPED TEETH
Descripción

DO YOU HAVE CAPPED TEETH

Tipo de datos

boolean

DO YOU HAVE LOOSE TEETH
Descripción

DO YOU HAVE LOOSE TEETH

Tipo de datos

boolean

Medikation
Descripción

Are you taking any medications NOW?

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0013227
Steroide
Descripción

Have you taken steroids in the last 6 months?

Tipo de datos

string

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

Health History - Women's health

DATE OF LAST PERIOD
Descripción

DATE OF LAST PERIOD

Tipo de datos

date

schwanger
Descripción

Are pregnant?

Tipo de datos

boolean

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

Weeks Gestation

Tipo de datos

integer

Estimated date of confinement (delivery date)
Descripción

EDC

Tipo de datos

date

Health History - Substance abuse and Smoking
Descripción

Health History - Substance abuse and Smoking

Drogenmissbrauch
Descripción

Substance abuse

Tipo de datos

string

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

Smoker

Tipo de datos

boolean

Alias
UMLS CUI-1
C0543414
What type of tobacco products?
Descripción

What type of tobacco products?

Tipo de datos

string

How much?
Descripción

How much?

Tipo de datos

string

Have you ever smoked /used tobacco products?
Descripción

Have you ever smoked /used tobacco products?

Tipo de datos

boolean

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

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

Tipo de datos

date

What type of tobacco products?
Descripción

What type of tobacco products?

Tipo de datos

string

How much?
Descripción

How much?

Tipo de datos

string

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

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

Tipo de datos

boolean

What type of tobacco products?
Descripción

What type of tobacco products?

Tipo de datos

string

How much?
Descripción

How much?

Tipo de datos

string

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

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

Tipo de datos

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)
Descripción

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

Tipo de datos

date

What type of tobacco products?
Descripción

What type of tobacco products?

Tipo de datos

string

How much?
Descripción

How much?

Tipo de datos

string

Tobacco/Smoking Cessation information/advice given to Patient
Descripción

Tobacco/Smoking Cessation information/advice given to Patient

Tipo de datos

boolean

Tobacco/Smoking Cessation information/advice given to Other
Descripción

Tobacco/Smoking Cessation information/advice given to Other

Tipo de datos

boolean

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

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

Tipo de datos

integer

How much alcohol?
Descripción

How much alcohol?

Tipo de datos

string

How often alcohol?
Descripción

How often alcohol?

Tipo de datos

string

RECREATIONAL DRUGS
Descripción

RECREATIONAL DRUGS

Tipo de datos

string

Immunizations
Descripción

Immunizations

Alias
UMLS CUI-1
C0020971
Impfung
Descripción

Immunizations

Tipo de datos

string

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

SPECIALTY CLINIC specific

SPECIALTY CLINIC specific
Descripción

SPECIALTY CLINIC specific

Tipo de datos

string

Nutrition
Descripción

Nutrition

Current Weight
Descripción

Current weight

Tipo de datos

float

Unidades de medida
  • kg
Alias
UMLS CUI-1
C0005910
kg
Have you experienced any unexplained weight loss or gain in the past 6 months?
Descripción

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

Tipo de datos

boolean

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

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

Tipo de datos

integer

Assistance / Mobility
Descripción

Assistance / Mobility

Do you live alone?
Descripción

Do you live alone?

Tipo de datos

boolean

Benötigt Unterstützung zuhause
Descripción

Does anyone assist you at home?

Tipo de datos

boolean

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

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

Tipo de datos

string

Equipment needed for WOUND(S)
Descripción

Equipment needed for WOUND(S)

Tipo de datos

string

Wunde
Descripción

Where is your wound(s) located?

Tipo de datos

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)?
Descripción

How long have you had the wound(s)?

Tipo de datos

date

How did the wounds start?
Descripción

How did the wounds start?

Tipo de datos

string

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

How have you been treating the wound(s)?

Tipo de datos

string

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Similar models

HIS

1 formularios
  1. StudyEvent: HIS
    1. HIS
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Age
Item
Alter
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
Height
Item
Größe
float
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Weight
Item
Gewicht
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI-1)
Temperature
Item
Temperatur
float
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
C0039476 (UMLS CUI-1)
Pulse Rate
Item
Pulsfrequenz
integer
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
C0232117 (UMLS CUI-1)
Respiratory rate
Item
Atemfrequenz
integer
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
C0231832 (UMLS CUI-1)
Blood Pressure
Item
Blutdruck
integer
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
C0005823 (UMLS CUI-1)
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
text
446050000, 59058001 (SNOMED CT 2011_0131)
PCP (HL7 V3 2006_05)
C0033131 (UMLS CUI-1)
C0017319 (UMLS CUI-2)
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
text
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)
C0149931 (UMLS CUI-1)
C0018681 (UMLS CUI-2)
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
text
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)
C0024117 (UMLS CUI-1)
C0006277 (UMLS CUI-2)
C0034067 (UMLS CUI-3)
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)
Smoker
Item
Raucher
boolean
C0543414 (UMLS CUI-1)
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
C0020971 (UMLS CUI-1)
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
float
C0005910 (UMLS CUI-1)
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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