ID
187
Description
Form from HIS OpenVistA
Keywords
Versions (4)
- 2/18/12 2/18/12 -
- 8/7/14 8/7/14 - Martin Dugas
- 8/9/14 8/9/14 - Martin Dugas
- 6/26/15 6/26/15 - Martin Dugas
Uploaded on
February 18, 2012
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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HIS HEALTH HISTORY I_ANESTHESIA MULTIDISCIPLINARY
HIS
- StudyEvent: HIS
Description
Anesthesia Specific
Description
Allergies
Data type
string
Alias
- UMLS CUI 2011AA
- C0020517
- SNOMED CT 2011_0131
- 257550005
- ICD-10-CM Version 2010
- T78.40
Description
Are you allergic to adhesive tape?
Data type
boolean
Description
Are you allergic to rubber products?
Data type
boolean
Description
Previous Surgeries?
Data type
string
Description
Surgery involving an anesthetic?
Data type
string
Description
General Anesthesia
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0002915
- SNOMED CT 2011_0131
- 50697003
- MedDRA 14.1
- 10018060
Description
Spinal Anesthesia
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0002928
- SNOMED CT 2011_0131
- 231249005
- MedDRA 14.1
- 10041536
Description
Epidural anaesthesia
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0002913
- SNOMED CT 2011_0131
- 18946005
- MedDRA 14.1
- 10015011
Description
Regional anesthesia
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0002911
- SNOMED CT 2011_0131
- 27372005
Description
Local anesthesia
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0002921
- SNOMED CT 2011_0131
- 386761002
- MedDRA 14.1
- 10024758
Description
anesthetic: Moderate sedation
Data type
boolean
Description
anesthetic: Axillary block
Data type
boolean
Description
Have you or a family member ever had a problem with an anesthesic? If Yes, describe:
Data type
string
Description
Health History - Endocrine
Description
Diabetes
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0011849
- SNOMED CT 2011_0131
- 191044006
Description
If Diabetes, last time med taken
Data type
string
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
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
Description
Health History - Neurologic
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
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
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
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
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
Description
Health History - Cardiovascular
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
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
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
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
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
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
Description
Health History - Respiratory
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
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
Description
Chronic Cough
Data type
string
Alias
- UMLS CUI 2011AA
- C0010201
- SNOMED CT 2011_0131
- 68154008
- MedDRA 14.1
- 10066656
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
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
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
Description
Health History - Genitourinary
Description
Abnormal Kidney function
Data type
string
Alias
- UMLS CUI 2011AA
- C1565489
- MedDRA 14.1
- 10038474
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
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
Description
Health History - Gastrointestinal
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
Description
Hepatitis/Liver Disease
Data type
string
Alias
- UMLS CUI 2011AA
- C0019158
- SNOMED CT 2011_0131
- 29001004
- MedDRA 14.1
- 10019717
Description
Freq. Indigestion/Reflux Disease
Data type
string
Alias
- UMLS CUI 2011AA
- C0558176
- SNOMED CT 2011_0131
- 225587003
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
Description
Health History - Other
Description
Bleed or Bruise Easily
Data type
string
Alias
- UMLS CUI 2011AA
- C1458140
- SNOMED CT 2011_0131
- 248250000
- MedDRA 14.1
- 10005134
Description
Blood Transfusions
Data type
string
Alias
- UMLS CUI 2011AA
- C1879316
- SNOMED CT 2011_0131
- 5447007
- MedDRA 14.1
- 10066152
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
Description
Bleeding Disorders
Data type
string
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
Description
HAVE YOU HAD ANY MAJOR ILLNESS
Data type
string
Description
DO YOU HAVE DENTURES
Data type
boolean
Description
DO YOU HAVE BRIDGEWORK
Data type
boolean
Description
DO YOU HAVE CAPPED TEETH
Data type
boolean
Description
DO YOU HAVE LOOSE TEETH
Data type
boolean
Description
Are you taking any medications NOW?
Data type
string
Alias
- UMLS CUI 2011AA
- C0013227
Description
Have you taken steroids in the last 6 months?
Data type
string
Alias
- UMLS CUI 2011AA
- C0038317
- SNOMED CT 2011_0131
- 116566001
Description
Health History - Women's health
Description
DATE OF LAST PERIOD
Data type
date
Description
Are pregnant?
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0549206
- MedDRA 14.1
- 10036586
Description
Weeks Gestation
Data type
integer
Description
EDC
Data type
date
Description
Health History - Substance abuse and Smoking
Description
Substance abuse
Data type
string
Alias
- UMLS CUI 2011AA
- C0740858
- SNOMED CT 2011_0131
- 66214007
- MedDRA 14.1
- 10066169
- LOINC Version 232
- MTHU019364
Description
Do you currently smoke/use tobacco products?
Data type
boolean
Alias
- UMLS CUI 2011AA
- CL025861
Description
What type of tobacco products?
Data type
string
Description
How much?
Data type
string
Description
Have you ever smoked /used tobacco products?
Data type
boolean
Description
When did you quit?(If has used products in the past 12 months,MUST give smoking cessation advice/information)
Data type
date
Description
What type of tobacco products?
Data type
string
Description
How much?
Data type
string
Description
Pediatric Smoking: Does anyone in your household currently use tobacco products?
Data type
boolean
Description
What type of tobacco products?
Data type
string
Description
How much?
Data type
string
Description
Has anyone in the house hold quit using tobacco products in the last 12 months?
Data type
boolean
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
Description
What type of tobacco products?
Data type
string
Description
How much?
Data type
string
Description
Tobacco/Smoking Cessation information/advice given to Patient
Data type
boolean
Description
Tobacco/Smoking Cessation information/advice given to Other
Data type
boolean
Description
In what format was the smoking cessation given (Verbal, Handwritten, Pre-printed)?
Data type
integer
Description
How much alcohol?
Data type
string
Description
How often alcohol?
Data type
string
Description
RECREATIONAL DRUGS
Data type
string
Description
Immunizations
Description
SPECIALTY CLINIC specific
Description
Nutrition
Description
Current Weight
Data type
integer
Description
Have you experienced any unexplained weight loss or gain in the past 6 months?
Data type
boolean
Description
As compared to normal, would you rate your food intake during the past month as either: CHANGED- MORE- LESS
Data type
integer
Description
Assistance / Mobility
Description
Do you live alone?
Data type
boolean
Description
Does anyone assist you at home?
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0578564
- SNOMED CT 2011_0131
- 301887005
Description
If yes, Name and phone number of person and/or facility that assists
Data type
string
Description
Equipment needed for WOUND(S)
Data type
string
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
Description
How long have you had the wound(s)?
Data type
date
Description
How did the wounds start?
Data type
string
Description
How have you been treating the wound(s)?
Data type
string
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