ID

45841

Description

Documentation of medical history for patients who present themselves in the outpatient clinic of Medical Clinic V - Clinic for Haematology, Oncology, Rheumatology - Heidelberg University Hospital

Keywords

Versions (2)
  1. 1/31/22 1/31/22 - Dr. Christian Niklas
  2. 8/17/23 8/17/23 - Martin Dugas
Copyright Holder

Sascha Dietrich; Tim Sauer

Uploaded on

August 17, 2023

DOI

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License

Creative Commons BY-SA 4.0
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Clinical Documentation Med. V Medical History B symptoms

German English

Medical History Hematology

1 forms  
  1. StudyEvent: Clinical Documentation Med. V - Medical History B-Symptomatics
    1. Medical History Hematology
B symptoms
Description

B symptoms

Alias
UMLS CUI [1]
C1706867
Have you had a fever lately?
Description

I.1

Data type

text

Alias
UMLS CUI [1]
C0015967
Do you have night sweats?
Description

I.2

Data type

text

Alias
UMLS CUI [1]
C0028081
Did you lose weight?
Description

I.3

Data type

text

Alias
UMLS CUI [1]
C1262477
Have you had any infectious diseases recently?
Description

I.4

Data type

text

Alias
UMLS CUI [1,1]
C0037088
UMLS CUI [1,2]
C3714514
Have you had less appetite lately?
Description

I.5

Data type

text

Alias
UMLS CUI [1]
C1971624
Have you been feeling less productive lately?
Description

I.6

Data type

text

Alias
UMLS CUI [1]
C1698094
Do you suffer from dizziness?
Description

I.7

Data type

text

Alias
UMLS CUI [1]
C0012833
Have you had a headache lately?
Description

I.8

Data type

text

Alias
UMLS CUI [1]
C0018681
Have you had shortness of breath lately?
Description

I.9

Data type

text

Alias
UMLS CUI [1]
C0013404
Previous illnesses
Description

Previous illnesses

Have you ever had a thrombosis in your legs?
Description

I.10

Data type

text

Alias
UMLS CUI [1]
C0149871
Do you suffer from circulatory disorders?
Description

I.14

Data type

text

Alias
UMLS CUI [1,1]
C0025962
UMLS CUI [1,2]
C0221099
Have you ever had a pulmonary embolism?
Description

I.11

Data type

text

Alias
UMLS CUI [1]
C0034065
If you are known to have another disease of the lungs, what is it?
Description

I.32

Data type

string

Alias
UMLS CUI [1]
C0024115
Have you ever had a heart attack?
Description

I.12

Data type

text

Alias
UMLS CUI [1]
C1275835
If you are known to have another heart condition, what is it?
Description

I.33

Data type

string

Alias
UMLS CUI [1]
C0018799
Have you ever had a stroke?
Description

I.13

Data type

text

Alias
UMLS CUI [1]
C0007785
If you are known to have another nervous system disorder, what is it?
Description

I.34

Data type

string

Alias
UMLS CUI [1]
C0027765
If you have a known gastrointestinal condition, what is it?
Description

I.35

Data type

string

Alias
UMLS CUI [1]
C0017178
If you have a known kidney disease, what is it?
Description

I.36

Data type

string

Alias
UMLS CUI [1]
C0022658
If you have a known liver disease, what is it?
Description

I.37

Data type

string

Alias
UMLS CUI [1]
C0023895
If you have a known thyroid condition, what is it?
Description

I.38

Data type

string

Alias
UMLS CUI [1]
C0040128
If you have a known pancreatic disorder, what is it?
Description

I.39

Data type

string

Alias
UMLS CUI [1]
C0030286
If you have a known disease of the urinary or genital organs, what is it?
Description

I.40

Data type

string

Alias
UMLS CUI [1]
C0080276
If you have a known allergy, what is it?
Description

I.41

Data type

string

Alias
UMLS CUI [1]
C0020517
If you have had surgery in the past, which surgeries were they?
Description

I.42

Data type

string

Alias
UMLS CUI [1]
C0543467
If you have any other pre-existing conditions, what are they?
Description

I.43

Data type

string

Alias
UMLS CUI [1,1]
C0521987
UMLS CUI [1,2]
C0205394
For women: Have you had a miscarriage?
Description

I.22

Data type

text

Alias
UMLS CUI [1]
C4552766
For women: Do you have increased menstrual bleeding?
Description

I.23

Data type

text

Alias
UMLS CUI [1]
C0699890
Complaints
Description

Complaints

Do you have stomach ache?
Description

I.15

Data type

text

Alias
UMLS CUI [1]
C0232487
Have you had a nosebleed lately?
Description

I.16

Data type

text

Alias
UMLS CUI [1]
C0014591
Have you had bleeding gums lately?
Description

I.17

Data type

text

Alias
UMLS CUI [1]
C0017565
Did you have blood in your urine?
Description

I.18

Data type

text

Alias
UMLS CUI [1]
C0018965
Did you have blood in your stool?
Description

I.19

Data type

text

Alias
UMLS CUI [1]
C0018932
Did you have more bruises?
Description

I.20

Data type

text

Alias
UMLS CUI [1]
C0475852
Has minor injuries bled longer lately?
Description

I.21

Data type

text

Alias
UMLS CUI [1]
C4022610
Do you suffer from diarrhea?
Description

I.24

Data type

text

Alias
UMLS CUI [1]
C0011991
Do you have swelling, e.g. on your arms or legs?
Description

I.25

Data type

text

Alias
UMLS CUI [1]
C0013604
Do you have sensory disturbances in your arms or legs?
Description

I.26

Data type

text

Alias
UMLS CUI [1]
C0152025
Have you ever had an allergic shock?
Description

I.27

Data type

text

Alias
UMLS CUI [1]
C0002792
Do you have itching or a rash?
Description

I.28

Data type

text

Alias
UMLS CUI [1]
C0033774
UMLS CUI [2]
C0015230
Do you have a known allergy to certain foods?
Description

I.29

Data type

text

Alias
UMLS CUI [1]
C0016470
If you have other complaints, what are they?
Description

I.30

Data type

text

Alias
UMLS CUI [1,1]
C0871764
UMLS CUI [1,2]
C0205394
Medication
Description

Medication

If you are currently taking any medications, what are they?
Description

I.31

Data type

text

Alias
UMLS CUI [1]
C1553892
Social history and noxious agents
Description

Social history and noxious agents

What is your occupation?
Description

I.44

Data type

string

Alias
UMLS CUI [1]
C0421456
social status
Description

I.45

Data type

text

Alias
UMLS CUI [1]
C0699806
Have you granted a Power of Attorney?
Description

I.46

Data type

text

Alias
UMLS CUI [1]
C2029796
Do you have a living will?
Description

I.47

Data type

text

Alias
UMLS CUI [1]
C0001683
If you are in need of care: what level of care do you have?
Description

I.48

Data type

text

Alias
UMLS CUI [1]
C1547668
If you drink alcohol regularly, how much per day?
Description

I.49

Data type

string

Alias
UMLS CUI [1]
C0001948
Smoking
Description

I.50

Data type

text

Alias
UMLS CUI [1]
C0453996
Do you regularly take non-steroidal painkillers (e.g. aspirin, diclofenac)?
Description

I.51

Data type

text

Alias
UMLS CUI [1]
C0003211
If you use drugs, what are they?
Description

I.52

Data type

string

Alias
UMLS CUI [1]
C0013146
If you have received chemotherapy or radiation before - when and what type of therapy?
Description

I.53

Data type

text

Alias
UMLS CUI [1,1]
C3665472
UMLS CUI [1,2]
C1522449
Family history
Description

Family history

What illnesses are known to your parents?
Description

I.54

Data type

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C0030551
If you have siblings and they are ill - which illnesses are these?
Description

I.55

Data type

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C0037047
If you have children and they are sick - which diseases are these?
Description

I.56

Data type

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C0008059
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Similar models

Medical History Hematology

1 forms
  1. StudyEvent: Clinical Documentation Med. V - Medical History B-Symptomatics
    1. Medical History Hematology
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
B symptoms
C1706867 (UMLS CUI [1])
Item
Have you had a fever lately?
text
C0015967 (UMLS CUI [1])
ja_nein
Code List
Have you had a fever lately?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you have night sweats?
text
C0028081 (UMLS CUI [1])
ja_nein
Code List
Do you have night sweats?
CL Item
yes (ja)
CL Item
no (nein)
Item
Did you lose weight?
text
C1262477 (UMLS CUI [1])
ja_nein
Code List
Did you lose weight?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you had any infectious diseases recently?
text
C0037088 (UMLS CUI [1,1])
C3714514 (UMLS CUI [1,2])
ja_nein
Code List
Have you had any infectious diseases recently?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you had less appetite lately?
text
C1971624 (UMLS CUI [1])
ja_nein
Code List
Have you had less appetite lately?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you been feeling less productive lately?
text
C1698094 (UMLS CUI [1])
ja_nein
Code List
Have you been feeling less productive lately?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you suffer from dizziness?
text
C0012833 (UMLS CUI [1])
ja_nein
Code List
Do you suffer from dizziness?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you had a headache lately?
text
C0018681 (UMLS CUI [1])
ja_nein
Code List
Have you had a headache lately?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you had shortness of breath lately?
text
C0013404 (UMLS CUI [1])
ja_nein
Code List
Have you had shortness of breath lately?
CL Item
yes (ja)
CL Item
no (nein)
Item Group
Previous illnesses
Item
Have you ever had a thrombosis in your legs?
text
C0149871 (UMLS CUI [1])
ja_nein
Code List
Have you ever had a thrombosis in your legs?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you suffer from circulatory disorders?
text
C0025962 (UMLS CUI [1,1])
C0221099 (UMLS CUI [1,2])
ja_nein
Code List
Do you suffer from circulatory disorders?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you ever had a pulmonary embolism?
text
C0034065 (UMLS CUI [1])
ja_nein
Code List
Have you ever had a pulmonary embolism?
CL Item
yes (ja)
CL Item
no (nein)
I.32
Item
If you are known to have another disease of the lungs, what is it?
string
C0024115 (UMLS CUI [1])
Item
Have you ever had a heart attack?
text
C1275835 (UMLS CUI [1])
ja_nein
Code List
Have you ever had a heart attack?
CL Item
yes (ja)
CL Item
no (nein)
I.33
Item
If you are known to have another heart condition, what is it?
string
C0018799 (UMLS CUI [1])
Item
Have you ever had a stroke?
text
C0007785 (UMLS CUI [1])
ja_nein
Code List
Have you ever had a stroke?
CL Item
yes (ja)
CL Item
no (nein)
I.34
Item
If you are known to have another nervous system disorder, what is it?
string
C0027765 (UMLS CUI [1])
I.35
Item
If you have a known gastrointestinal condition, what is it?
string
C0017178 (UMLS CUI [1])
I.36
Item
If you have a known kidney disease, what is it?
string
C0022658 (UMLS CUI [1])
I.37
Item
If you have a known liver disease, what is it?
string
C0023895 (UMLS CUI [1])
I.38
Item
If you have a known thyroid condition, what is it?
string
C0040128 (UMLS CUI [1])
I.39
Item
If you have a known pancreatic disorder, what is it?
string
C0030286 (UMLS CUI [1])
I.40
Item
If you have a known disease of the urinary or genital organs, what is it?
string
C0080276 (UMLS CUI [1])
I.41
Item
If you have a known allergy, what is it?
string
C0020517 (UMLS CUI [1])
I.42
Item
If you have had surgery in the past, which surgeries were they?
string
C0543467 (UMLS CUI [1])
I.43
Item
If you have any other pre-existing conditions, what are they?
string
C0521987 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item
For women: Have you had a miscarriage?
text
C4552766 (UMLS CUI [1])
ja_nein
Code List
For women: Have you had a miscarriage?
CL Item
yes (ja)
CL Item
no (nein)
Item
For women: Do you have increased menstrual bleeding?
text
C0699890 (UMLS CUI [1])
ja_nein
Code List
For women: Do you have increased menstrual bleeding?
CL Item
yes (ja)
CL Item
no (nein)
Item Group
Complaints
Item
Do you have stomach ache?
text
C0232487 (UMLS CUI [1])
ja_nein
Code List
Do you have stomach ache?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you had a nosebleed lately?
text
C0014591 (UMLS CUI [1])
ja_nein
Code List
Have you had a nosebleed lately?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you had bleeding gums lately?
text
C0017565 (UMLS CUI [1])
ja_nein
Code List
Have you had bleeding gums lately?
CL Item
yes (ja)
CL Item
no (nein)
Item
Did you have blood in your urine?
text
C0018965 (UMLS CUI [1])
ja_nein
Code List
Did you have blood in your urine?
CL Item
yes (ja)
CL Item
no (nein)
Item
Did you have blood in your stool?
text
C0018932 (UMLS CUI [1])
ja_nein
Code List
Did you have blood in your stool?
CL Item
yes (ja)
CL Item
no (nein)
Item
Did you have more bruises?
text
C0475852 (UMLS CUI [1])
ja_nein
Code List
Did you have more bruises?
CL Item
yes (ja)
CL Item
no (nein)
Item
Has minor injuries bled longer lately?
text
C4022610 (UMLS CUI [1])
ja_nein
Code List
Has minor injuries bled longer lately?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you suffer from diarrhea?
text
C0011991 (UMLS CUI [1])
ja_nein
Code List
Do you suffer from diarrhea?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you have swelling, e.g. on your arms or legs?
text
C0013604 (UMLS CUI [1])
ja_nein
Code List
Do you have swelling, e.g. on your arms or legs?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you have sensory disturbances in your arms or legs?
text
C0152025 (UMLS CUI [1])
ja_nein
Code List
Do you have sensory disturbances in your arms or legs?
CL Item
yes (ja)
CL Item
no (nein)
Item
Have you ever had an allergic shock?
text
C0002792 (UMLS CUI [1])
ja_nein
Code List
Have you ever had an allergic shock?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you have itching or a rash?
text
C0033774 (UMLS CUI [1])
C0015230 (UMLS CUI [2])
ja_nein
Code List
Do you have itching or a rash?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you have a known allergy to certain foods?
text
C0016470 (UMLS CUI [1])
ja_nein
Code List
Do you have a known allergy to certain foods?
CL Item
yes (ja)
CL Item
no (nein)
I.30
Item
If you have other complaints, what are they?
text
C0871764 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Medication
I.31
Item
If you are currently taking any medications, what are they?
text
C1553892 (UMLS CUI [1])
Item Group
Social history and noxious agents
I.44
Item
What is your occupation?
string
C0421456 (UMLS CUI [1])
Item
social status
text
C0699806 (UMLS CUI [1])
Sozialstatus
Code List
social status
CL Item
single (1)
CL Item
living in partnership (2)
CL Item
married (3)
CL Item
divorced (4)
CL Item
widowed (5)
Item
Have you granted a Power of Attorney?
text
C2029796 (UMLS CUI [1])
ja_nein
Code List
Have you granted a Power of Attorney?
CL Item
yes (ja)
CL Item
no (nein)
Item
Do you have a living will?
text
C0001683 (UMLS CUI [1])
ja_nein
Code List
Do you have a living will?
CL Item
yes (ja)
CL Item
no (nein)
I.48
Item
If you are in need of care: what level of care do you have?
text
C1547668 (UMLS CUI [1])
I.49
Item
If you drink alcohol regularly, how much per day?
string
C0001948 (UMLS CUI [1])
Item
Smoking
text
C0453996 (UMLS CUI [1])
Nikotin
Code List
Smoking
CL Item
never smoked (0)
C0425293 (UMLS CUI [1,1])
CL Item
active smoker (1)
C0543414 (UMLS CUI [1,1])
CL Item
former smoker (2)
C0337671 (UMLS CUI [1,1])
Item
Do you regularly take non-steroidal painkillers (e.g. aspirin, diclofenac)?
text
C0003211 (UMLS CUI [1])
ja_nein
Code List
Do you regularly take non-steroidal painkillers (e.g. aspirin, diclofenac)?
CL Item
yes (ja)
CL Item
no (nein)
I.52
Item
If you use drugs, what are they?
string
C0013146 (UMLS CUI [1])
I.53
Item
If you have received chemotherapy or radiation before - when and what type of therapy?
text
C3665472 (UMLS CUI [1,1])
C1522449 (UMLS CUI [1,2])
Item Group
Family history
I.54
Item
What illnesses are known to your parents?
text
C0241889 (UMLS CUI [1,1])
C0030551 (UMLS CUI [1,2])
I.55
Item
If you have siblings and they are ill - which illnesses are these?
text
C0241889 (UMLS CUI [1,1])
C0037047 (UMLS CUI [1,2])
I.56
Item
If you have children and they are sick - which diseases are these?
text
C0241889 (UMLS CUI [1,1])
C0008059 (UMLS CUI [1,2])
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