| Version 18 (modified by , 12 years ago) ( diff ) |
|---|
i2b2 Import from Onyx Mapping Version 1
The mapping is made up of 13 questionnaires. These are:
- Acute Verbal Consent for samples collection
- Participant Consent
- Paper Consent
- Recruitment Context
- Risk Factor
- Patient-reported medical history
- Samples Preliminary
- Blood samples collection
- Urine sample collection
- End of patient contact
- Notes-recorded medical history
- Data submission
- Conclusion
The mapping of each questionnaire is show in the sections below:
Acute Verbal Consent for samples collection
Export folder: VerbalConsentQuestionnaire
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Was acute verbal consent given | Radio button: yes,no | n |
| Name of witness | Free text with radio button | y |
Participant Consent
Export folder: Consent ?
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Type of consent | Radio button: Electronic, Paper | n |
| Consent form language | Select: various languages | n |
| Consent Confirmation (paper only?) | Radio buttons: 'read and signed', 'refused to sign' | n |
QUESTION: The confirmation comes through as consent_q[1-5] and consent_q[1-5]_signed. Does this relate to the different language options?
Paper Consent
Export folder: ManualConsentQuestionnaire?
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Does the participant understand the request for consent? | Radio button: yes, no | y |
| Does the participant consent to donate blood and urine | Radio button: yes, no | y |
| Does the participant consent to entry in the BRICCS database? | Radio button: yes, no | y |
| Does the participant consent to further contact from BRU? | Radio button: yes, no | y |
| Does the participant understand the rules of withdrawal? | Radio button: yes, no | y |
Recruitment Context
Export folder: RecruitmentContextQuestionnaire
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Interview Language | Select: languages | y |
| Recruitment episode type | Radio button: inpatient, outpatient, healthy control, study specific, don't know | y |
| Inpatient admission type | Radio button: Actute, Elective, Don't know | y |
| Hospital | Radio button: Glenfield, LGH, LRI, Don't know | y |
| Admitting Ward | Select: list of wards, and radio button: don't know | y |
| Admitting Consultant | Select: list of consultants, and radio button: don't know | y |
| Outpatient clinic attended | select: list of clinics, and radio button: don't know | y |
| Consultant | Select: list of consultants, and radio button: don't know | y |
| Study Reference | Radio button: GeneFast AS Study, Study Reference2, Study Reference3, Don't know | y |
Risk Factor
Export folder: RiskFactorQuestionnaire
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Have you ever smoked or used any tobacco or nicotine product? | Radio button: no, yes, prefer not to answer, don't know | y |
| Which of the following have you ever smoked or used? | tick boxes: cigarettes, cigars, pipe tobacco, snuff or chewing tobacco, any other | y |
| Have you ever smoked cigarettes on most days? | Radio button: no, yes, prefer not to answer, Don't know | y |
| Do you currently smoke cigarettes | Radio button: y, n, pnta, dk | y |
| On average, how many cigarettes did you smoke per day when you were smoking the most | numeric box, pnta, dk | y |
| How old were you when you began smoking cigarettes on most days | numeric box, pnta, dk | y |
| How old were you when you stopped smoking cigarettes | numeric box, pnta, dk | y |
| On average, how many cigarettes do you currently smoke per day? | numeric box, pnta, dk | y |
| When was the last time you had a cigarette | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
| Have you ever smoked cigars regularly | Radio buttons: y, n, pnta, dk | y |
| Do you currently smoke cigars | Radio buttons: y, n, pnta, dk | y |
| On average, how many cigars did you smoke per day when you were smoking the most | numeric box, pnta, dk | y |
| How old were you when you began smoking cigars on most days | numeric box, pnta, dk | y |
| How old were you when you stopped smoking cigars | numeric box, pnta, dk | y |
| On average, how many cigars do you currently smoke per day? | numeric box, pnta, dk | y |
| When was the last time you had a cigarette | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
| Have you ever smoked a pipe regularly | Radio buttons: y, n, pnta, dk | y |
| Do you currently smoke a pipe | Radio buttons: y, n, pnta, dk | y |
| How much tobacco did you smoke per day when you were smoking the most | numeric box, pnta, dk | y |
| How old were you when you began smoking a pipe on most days | numeric box, pnta, dk | y |
| How old were you when you stopped smoking a pipe | numeric box, pnta, dk | y |
| How much tobacco do you currently smoke per day? | numeric box, pnta, dk | y |
| When was the last time you smoked a pipe | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
| Have you ever used snuff or chewing tobacco regularly | Radio buttons: y, n, pnta, dk | y |
| Do you currently use snuff or chewing tobacco | Radio buttons: y, n, pnta, dk | y |
| How much snuff or chewing tobacco did you smoke per day when you were using the most | numeric box, pnta, dk | y |
| How old were you when you began using snuff or chewing tobacco | numeric box, pnta, dk | y |
| How old were you when you stopped using snuff or chewing tobacco | numeric box, pnta, dk | y |
| How much snuff or chewing tobacco do you use per week? | numeric box, pnta, dk | y |
| When was the last time you has snuff or chewing tobacco | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
| Have you ever used any other tobacco or nicotine product for at least 6 months | y, n, pnta, dk | y |
| Do you currently use any other tobacco or nicotine product | y, n, pnta, dk | y |
| How much of the tobacco or nicotine product per week did you use when you were using the most? | numeric box, pnta, dk | y |
| How old were you when you began using the tobacco or nicotine product? | numeric box, pnta, dk | y |
| How old were you when you stopped using the tobacco or nicotine product? | numeroc box, pnta, dk | y |
| How much of the tobacco or nicotine product do you use per week? | numeric box, pnta, dk | y |
| When was the last time you had any tobacco or nicotine? | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
| Have you ever drunk alcohol? | y, n, pnta, dk | y |
| Have you ever drunk alcohol at least once per week? | y, n, pnta, dk | y |
| Do you currently drink alcohol at least once per week? | y, n, pnta, dk | y |
| How many pints of beer do you drink in a typical week? | numeric box, pnta, dk | y |
| How many glasses of white wine do you drink in a typical week? | numeric box, pnta, dk | y |
| How many glasses of red wine do you drink in a typical week? | numeric box, pnta, dk | y |
| How many glasses of rose wine do you drink in a typical week? | numeric box, pnta, dk | y |
| How many measures of spirits do you drink in a typical week? | numeric box, pnta, dk | y |
| How old were you when you began drinking alcohol? | numeric box, pnta, dk | y |
| When was the last time you had a drink containing alcohol? | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
| How would you describe your diet? | Radio buttons: various diets | y |
| If you work, does your work involve any physical activity? | Radio buttons | y |
| Apart from work, do you undertake any regular physical exercise over and above that of daily living? | Radio buttons | y |
| Number of Family members | see below | y |
| How many brothers do you have? | numeric, pnta, dk | n |
| How many sisters do you have? | numeric, pnta, dk | n |
| How many children do you have? | numeric, pnta, dk | n |
| Have any of your relatives suffered angina or other Coronary Artery Disease? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| Have any of your relatives suffered a heart attack or Myocardial Infarction? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| Have any of your relatives ever been diagnosed with heart failure? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| Have any of your relatives ever suffered Atrial Fibrillation (AF)? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| Have any of your relatives ever suffered a stroke or CVA? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| Have any of your relatives been diagnosed with high blood pressure? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| Have any of your relatives been diagnosed with valvular heart disease? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| At what age did they first suffer from angina or Coronary Artery Disease? | see below | y |
| Father | numeric box, pnta, dk | n |
| Mother | numeric box, pnta, dk | n |
| Brother | numeric box, pnta, dk | n |
| Sister | numeric box, pnta, dk | n |
| Child | numeric box, pnta, dk | n |
| Have they received treatment for their angina or Coronary Artery Disease? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| At what age did they suffer their first heart attack or Myocardial Infarction? | see below | y |
| Father | numeric box, pnta, dk | n |
| Mother | numeric box, pnta, dk | n |
| Brother | numeric box, pnta, dk | n |
| Sister | numeric box, pnta, dk | n |
| Child | numeric box, pnta, dk | n |
| Have they received treatment for their angina or Coronary Artery Disease? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| At what age did they first suffer from heart failure? | see below | y |
| Father | numeric box, pnta, dk | n |
| Mother | numeric box, pnta, dk | n |
| Brother | numeric box, pnta, dk | n |
| Sister | numeric box, pnta, dk | n |
| Child | numeric box, pnta, dk | n |
| Have they received treatment for their heart failure? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| At what age did they first suffer from Atrial Fibrillation? | see below | y |
| Father | numeric box, pnta, dk | n |
| Mother | numeric box, pnta, dk | n |
| Brother | numeric box, pnta, dk | n |
| Sister | numeric box, pnta, dk | n |
| Child | numeric box, pnta, dk | n |
| Have they received treatment for their Atrial Fibrillation? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| At what age did they suffer their first stroke or CVA? | see below | y |
| Father | numeric box, pnta, dk | n |
| Mother | numeric box, pnta, dk | n |
| Brother | numeric box, pnta, dk | n |
| Sister | numeric box, pnta, dk | n |
| Child | numeric box, pnta, dk | n |
| Were they treated for the stroke or CVA? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| At what age did they first suffer from high blood pressure? | see below | y |
| Father | numeric box, pnta, dk | n |
| Mother | numeric box, pnta, dk | n |
| Brother | numeric box, pnta, dk | n |
| Sister | numeric box, pnta, dk | n |
| Child | numeric box, pnta, dk | n |
| Have they received treatment for their high blood pressure? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| At what age did they first suffer from valvular heart disease? | see below | y |
| Father | numeric box, pnta, dk | n |
| Mother | numeric box, pnta, dk | n |
| Brother | numeric box, pnta, dk | n |
| Sister | numeric box, pnta, dk | n |
| Child | numeric box, pnta, dk | n |
| Have they received treatment for their valvular heart disease? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| Are all of your relatives still alive? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| Do you know the cause of your father's death? | Radio buttons | y |
| Do you know the cause of your Mother's death? | Radio buttons | y |
| Do you know the cause of your brother's death? | Radio buttons | y |
| Do you know the cause of your sister's death? | Radio buttons | y |
| Do you know the cause of your child's death? | Radio buttons | y |
| At what age did they die? | see below | y |
| Father | numeric box, pnta, dk | n |
| Mother | numeric box, pnta, dk | n |
| Brother | numeric box, pnta, dk | n |
| Sister | numeric box, pnta, dk | n |
| Child | numeric box, pnta, dk | n |
| Was their death sudden and unexpected? | see below | y |
| Father | Radio buttons: y, n, pnta, dk | n |
| Mother | Radio buttons: y, n, pnta, dk | n |
| Brother | Radio buttons: y, n, pnta, dk | n |
| Sister | Radio buttons: y, n, pnta, dk | n |
| Child | Radio buttons: y, n, pnta, dk | n |
| What is your current marital status? | Radio buttons | y |
| Do you live with a spouse or partner? | Radio buttons | y |
| How many people live in your household? | Radio buttons | y |
| What is your current work status? | Radio buttons | y |
| What was the highest level of education you completed? | Radio buttons | y |
| Which of the following best describes the work you do or did? | Radio buttons | y |
Patient-reported medical history
Export folder:
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Have you ever suffered from high blood pressure? | y, n, pnta, dk | y |
| When did you first suffer from high blood pressure? | numeric box, pnta, dk | y |
| Have you received treatment for your high blood pressure? | y, n, pnta, dk | y |
| Have you ever suffered from diabetes? | y, n, pnta, dk | y |
| Which type of diabetes? | radio button list | y |
| When did you first suffer from diabetes? | numeric box, pnta, dk | y |
| Have you received treatment for your diabetes? | y, n, pnta, dk | y |
| What treatment are you receiving for your diabetes? | radio button list | y |
| Have you ever suffered from high cholesterol? | y, n, pnta, dk | y |
| When did you first suffer from high cholesterol? | numeric box, pnta, dk | y |
| Have you received treatment for your high cholesterol? | y, n, pnta, dk | y |
| Have you ever suffered a heart attack or myocardial infarction (M.I.)? | y, n, pnta, dk | y |
| How many heart attacks or MIs have you had? | numeric box, pnta, dk | y |
| Year of occurrence of each MI (one per instance) | numeric box, pnta, dk | y |
| Have you received treatment for your MI? | y, n, pnta, dk | y |
| Have you ever had a stroke or a cerebrovascular accident (CVA)? | y, n, pnta, dk | y |
| How many CVAs have you suffered? | numeric box, pnta, dk | y |
| Year of occurrence of each CVA (one per instance) | numeric box, pnta, dk | y |
| Have you received treatment for your CVA? | y, n, pnta, dk | y |
| Have you ever suffered from transient ischaemic attack (TIA)? | y, n, pnta, dk | y |
| How many TIAs have you suffered? | numeric box, pnta, dk | y |
| Year of occurrence of each TIA (one per instance) | numeric box, pnta, dk | y |
| Have you received treatment for your TIA? | y, n, pnta, dk | y |
| Have you ever suffered from angina? | y, n, pnta, dk | y |
| When did you first suffer from angina? | numeric box, pnta, dk | y |
| Have you received treatment for your angina? | y, n, pnta, dk | y |
| Have you ever suffered from peripheral vascular disease (PVD)? | y, n, pnta, dk | y |
| When did you first suffer from peripheral vascular disease (PVD)? | numeric box, pnta, dk | y |
| Have you received treatment for your PVD? | y, n, pnta, dk | y |
| Have you ever suffered from valvular heart disease? | y, n, pnta, dk | y |
| Which type of Valvular Heart Disease have you had? | radio button list | y |
| When did you first suffer from valvular heart disease? | numeric box, pnta, dk | y |
| Have you received treatment for your valvular heart disease? | y, n, pnta, dk | y |
| Have you ever suffered from an aortic aneurysm? | y, n, pnta, dk | y |
| When did you first suffer from aortic aneurysm? | numeric box, pnta, dk | y |
| Have you received treatment for your aortic aneurysm? | y, n, pnta, dk | y |
| Have you ever suffered from chronic renal failure? | y, n, pnta, dk | y |
| When did you first suffer from chronic renal failure? | numeric box, pnta, dk | y |
| Have you received treatment for your chronic renal failure? | y, n, pnta, dk | y |
| Have you ever suffered from chronic obstructive airway disease (COAD) or chronic obstructive pulmonary disease (COPD)? | y, n, pnta, dk | y |
| When did you first suffer from COAD or COPD? | numeric box, pnta, dk | y |
| Have you received treatment for your COAD or COPD? | y, n, pnta, dk | y |
| Have you ever suffered from liver disease? | y, n, pnta, dk | y |
| When did you first suffer from liver disease? | numeric box, pnta, dk | y |
| Have you received treatment for your liver disease? | y, n, pnta, dk | y |
| Have you ever suffered from asthma? | y, n, pnta, dk | y |
| When did you first suffer from asthma? | numeric box, pnta, dk | y |
| Have you received treatment for your asthma? | y, n, pnta, dk | y |
| Have you ever suffered from Atrial Fibrillation (AF)? | y, n, pnta, dk | y |
| When did you first suffer from AF? | numeric box, pnta, dk | y |
| Have you received treatment for your AF? | y, n, pnta, dk | y |
| Have you ever suffered from any other heart rhythm disturbance? | y, n, pnta, dk | y |
| When did you first suffer from other heart rhythm disturbance? | numeric box, pnta, dk | y |
| Have you received treatment for your other heart rhythm disturbance? | y, n, pnta, dk | y |
| Past History of Interventions | tickbox list with radio buttons for none & unknown | y |
| How many times have you undergone CABG? | numeric box | y |
| Enter the year for each CABG (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you undergone Valve Surgery? | numeric box | y |
| Enter the year for each Valve_Surgery (one per occurrance) | numeric box and unknown radio button | y |
| In which year was your TAVI performed? | numeric box and unknown radio button | y |
| How many times have you undergone a Primary PCI? | numeric box | y |
| Enter the year for each Primary PCI (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you undergone a PCI other than a Primary PCI? | numeric box | y |
| When did you have the other PCI procedures? (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had pacemaker surgery? | numeric box | y |
| Enter the year for each pacemaker. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had an ICD implanted? | numeric box | y |
| Enter the year for each ICD. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had DC cardioversion? | numeric box | y |
| Enter the year for each DC cardioversion. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had an LVAD fitted? | numeric box | y |
| Enter the year for each LVAD. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had thrombolysis? | numeric box | y |
| Enter the year for each thrombolysis treatment. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had an ablation? | numeric box | y |
| Enter the year for each ablation. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had an Aortic Balloon Pump fitted? | numeric box | y |
| Enter the year for each Aortic Balloon Pump. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had a bare metal stent fitted? | numeric box | y |
| Enter the year for each bare metal stent. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had a drug-eluting stent fitted? | numeric box | y |
| How many times have you had a drug-eluting stent fitted. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had ? | numeric box | y |
| Enter the year for each CPAP. (one per occurrance) | numeric box and unknown radio button | y |
| How many times have you had a heart transplant ? | numeric box | y |
| Enter the year for each heart transplant. (one per occurrance) | numeric box and unknown radio button | y |
Samples Preliminary
Export folder: SamplesPreliminaryQuestionnaire
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Do you have a blood clotting disease such as haemophilia? | y,n,pnta,dk | y |
| Have you received a blood transfusion or donated blood in the past 24 hours? | y,n,pnta,dk | y |
| Have you received a blood transfusion in the past three months? | y,n,pnta,dk | y |
| Have you received radiotherapy or chemotherapy treatment in the past twelve weeks? | y,n,pnta,dk | y |
| When was the last time you had something to eat | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
| When was the last time you had anything to drink other than plain water | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
| When was the last time you had a drink containing caffeine, including tea, coffee or an energy drink? | Complex radio buttons: (Select: today, yesterday; Select: hour; Select: minute) or (More than 24 hours) | y |
Blood samples collection
Export folder: BloodSamplesCollection
I suspect this is going to be more comlicated than I can replicate.
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Tube barcode | textbox | n |
Urine sample collection
Export folder: UrineSamplesQuestionnaire
I suspect this is going to be more comlicated than I can replicate.
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Tube barcode | textbox | n |
End of patient contact
Export folder: EndContactQuestionnaire
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Measurement around the waist (in centimetres): | Numeric, or radio buttons: unable to measure, participant refused | y |
| Measurement around the hips (in centimetres): | Numeric, or radio buttons: unable to measure, participant refused | y |
| Skin-fold measurement - biceps (in millimetres): | Numeric, or radio buttons: unable to measure, participant refused | y |
| Skin-fold measurement - triceps (in millimetres): | Numeric, or radio buttons: unable to measure, participant refused | y |
| Skin-fold measurement - subscapular (in millimetres): | Numeric, or radio buttons: unable to measure, participant refused | y |
| Skin-fold measurement - supra-iliac (in millimetres): | Numeric, or radio buttons: unable to measure, participant refused | y |
| Primary email address | textbox | y |
| Additional email address | textbox | y |
Notes-recorded medical history
Export folder:
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Is hypertension documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of high blood pressure? | Numeric or Radio button: unknown | y |
| Is diabetes documented in the notes? | Radio button: y, n, unknown | y |
| Which type of diabetes? | Radio button list | y |
| Year of onset of diabetes? | Numeric or Radio button: unknown | y |
| Is high cholesterol documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of high cholesterol? | Numeric or Radio button: unknown | y |
| Is heart attack or myocardial infarction (M.I.) documented in the notes? | Radio button: y, n, unknown | y |
| How many MIs have been documented? | Numeric or Radio button: unknown | y |
| Year of occurrence of each MI: (one per occurrence) | Numeric or Radio button: unknown | y |
| Is stroke or a cerebrovascular accident (CVA) documented in the notes? | Radio button: y, n, unknown | y |
| How many CVAs have been documented? | Numeric or Radio button: unknown | y |
| Year of occurrence of each CVA: (one per occurrence) | Numeric or Radio button: unknown | y |
| Is transient ischaemic attack (TIA) documented in the notes? | Radio button: y, n, unknown | y |
| How many TIAs have been documented? | Numeric or Radio button: unknown | y |
| Year of occurrence of each TIA: (one per occurrence) | Numeric or Radio button: unknown | y |
| Is angina documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of angina? | Numeric or Radio button: unknown | y |
| Is peripheral vascular disease (PVD) documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of peripheral vascular disease (PVD)? | Numeric or Radio button: unknown | y |
| Is valvular heart disease documented in the notes? | Radio button: y, n, unknown | y |
| Which type of Valvular Heart Disease? | Radio button list | y |
| Year of onset of valvular heart disease? | Numeric or Radio button: unknown | y |
| Is an aortic aneurysm documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of aortic aneurysm? | Numeric or Radio button: unknown | y |
| Is chronic renal failure documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of chronic renal failure? | Numeric or Radio button: unknown | y |
| Is chronic obstructive airway disease (COAD) or chronic obstructive pulmonary disease (COPD) documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of chronic obstructive airway disease (COAD) or chronic obstructive pulmonary disease (COPD)? | Numeric or Radio button: unknown | y |
| Is liver disease documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of liver disease? | Numeric or Radio button: unknown | y |
| Is asthma documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of asthma? | Numeric or Radio button: unknown | y |
| Is Atrial Fibrillation (AF) documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of AF? | Numeric or Radio button: unknown | y |
| Is there any other heart rhythm disturbance documented in the notes? | Radio button: y, n, unknown | y |
| Year of onset of heart rhythm disturbance? | Numeric or Radio button: unknown | y |
| History of Interventions | Text box list with radio buttons for none and unknown | y |
| How many times has the participant undergone CABG? | numeric box | y |
| Enter the year for each CABG (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant undergone Valve Surgery? | numeric box | y |
| Enter the year for each Valve_Surgery (one per occurrance) | numeric box and unknown radio button | y |
| Enter the year TAVI was performed? | numeric box and unknown radio button | y |
| How many times has the participant undergone Primary PCI? | numeric box | y |
| Enter the year for each Primary PCI (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant undergone PCI other than Primary PCI? | numeric box | y |
| Enter the year of each other PCI? (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant undergone Pacemaker surgery? | numeric box | y |
| Enter the year for each pacemaker. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had a ICD implanted? | numeric box | y |
| Enter the year for each ICD. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant undergone DC Cardioversion? | numeric box | y |
| Enter the year for each DC cardioversion. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had LVAD surgery? | numeric box | y |
| Enter the year for each LVAD. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had thrombolysis? | numeric box | y |
| Enter the year for each thrombolysis treatment. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had an ablation? | numeric box | y |
| Enter the year for each ablation. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had an Aortic Balloon Pump fitted? | numeric box | y |
| Enter the year for each Aortic Balloon Pump. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had a bare metal stent fitted? | numeric box | y |
| Enter the year for each bare metal stent. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had a drug-eluting stent fitted? | numeric box | y |
| Enter the year for each drug-eluting stent. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had CPAP treatment ? | numeric box | y |
| Enter the year for each CPAP. (one per occurrance) | numeric box and unknown radio button | y |
| How many times has the participant had a heart transplant ? | numeric box | y |
| Enter the year for each heart transplant. (one per occurrance) | numeric box and unknown radio button | y |
Data submission
Export folder: DataSubmissionQuestionnaire
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Principal Symptoms | Tickbox list, radio buttons for none or unknown | y |
| Please supply details of the additional symptom(s) | text area | y |
| When was the First Onset of Symptoms? | (numeric year and select month) or (unknown radio button) | y |
| Presenting Primary Diagnosis | radio button list | y |
| Acute associated diagnoses | tickbox list with radio button for none | y |
| Please supply details of the other secondary diagnosis | text area | y |
| Interventions during this clinical episode | see below | y |
| CABG Coronary Artery Bypass Graft | Date | n |
| Valve Surgery | Date | n |
| TAVI - Transcatheter Aortic Valve Implantation | Date | n |
| PPCI - Primary Percutaneous Coronary Intervention | Date | n |
| Other PCI | Date | n |
| Pacemaker insertion | Date | n |
| ICD - Implantable Cardioverter Defibrillator | Date | n |
| DC Cardioversion | Date | n |
| LVAD - Left Ventricular Assist Device | Date | n |
| Thrombolysis | Date | n |
| Electrophysiology (EP) / Radiofrequency (RF) Ablation | Date | n |
| Coronary Angiography | Date | n |
| First recorded Heart Rate during this episode of care | numeric or radio button: not recorded | n |
| First recorded Systolic Blood Pressure | numeric or radio button: not recorded | n |
| First recorded Diastolic Blood Pressure | numeric or radio button: not recorded | n |
| Latest recorded Heart Rate | numeric or radio button: not recorded | n |
| Latest recorded Systolic Blood Pressure | numeric or radio button: not recorded | n |
| Latest recorded Diastolic Blood Pressure | numeric or radio button: not recorded | n |
| Height | numeric or radio button: not recorded | n |
| Weight | numeric or radio button: not recorded | n |
Conclusion
Export folder: ConclusionQuestionnaire
Visible fields on the form:
| Label | Answer Type | Has comment |
|---|---|---|
| Discharge Method | Radio button list | y |
| Drugs on discharge or departure from clinic | tickbox list or radio buttons: none, unknown |
Note:
See TracWiki
for help on using the wiki.
