Data Dictionary for mp2cev

Number of Blaise fields: 637

Seq # Var Question Data Type/Coding
1 projid MAP 2001 BASELINE Clinical Evaluation (Version: 03/02/2022) Enter project ID number. String[8]
2 folder Type in folder color. F/U Year Folder Baseline (manilla) String[8]
3 visit Enter visit code (check folder color): CODE F/U Year Folder 00 = Baseline (manilla) String[2]
4 vervisit Please verify visit and folder color. visit = ^visitnum folder = ^folder1 Is this correct? If not, please page up and correct folder color. 1= Yes
5 formno Form Number String[6]
6 version Version Number String[4]
7 autodate Automatic Date. Date type
8 autotime Automatic Time. TimeType
9 autolog Automatic Logged Date. Date type
10 intid INTERVIEWER ID 100 .. 997
11 compid Laptop ID String[20]
12 dateint Date of interview Date type
13 sex Subject's sex. 1= Male 2= Female
14 autotm [COMPUTER CLOCK TIME] String[8]
15 q1drg Now I would like to ask you about medicines. 1. During the past two weeks, HAVE YOU TAKEN ANY MEDICINE PRESCRIBED by a doctor? 1= Yes 2= No
16 q2drg 2. Now, about supplements not usually prescribed by a doctor such as vitamin preparations including multivitamins, vitamin C, vitamin A, vitamin D, or vitamin E . . . During the past two weeks have you taken any of these or any other vitamin preparations? 1= Yes 2= No
17 q3drg 3. We are also interested in other medicines or supplements not prescribed by a doctor such as aspirin, Tylenol, Bufferin, Anacin, headache pills or pain killers, laxatives or bowel medicines, cold medicines, cough medicines, sleep medicines, antacids or stomach medicines, ointments or salves . . . During the past two weeks have you taken any of these or any other medicines from the drug store? 1= Yes 2= No
18 q4drg 4. May I please see all these medicines for the past two weeks? [INTERVIEWER RECORD ALL MEDICINES TAKEN WITHIN THE PAST 2 WEEKS WHETHER AVAILABLE FOR INSPECTION OR NOT] [ENTER TOTAL NUMBER OF MEDICINES TO BE RECORDED] 0 .. 50
19 name00 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
20 stren00 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
21 drgnm00 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
22 seen00 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
23 dosage00 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
24 recd00 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
25 name01 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
26 stren01 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
27 drgnm01 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
28 seen01 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
29 dosage01 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
30 recd01 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
31 name02 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
32 stren02 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
33 drgnm02 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
34 seen02 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
35 dosage02 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
36 recd02 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
37 name03 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
38 stren03 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
39 drgnm03 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
40 seen03 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
41 dosage03 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
42 recd03 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
43 name04 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
44 stren04 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
45 drgnm04 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
46 seen04 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
47 dosage04 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
48 recd04 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
49 name05 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
50 stren05 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
51 drgnm05 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
52 seen05 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
53 dosage05 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
54 recd05 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
55 name06 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
56 stren06 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
57 drgnm06 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
58 seen06 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
59 dosage06 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
60 recd06 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
61 name07 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
62 stren07 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
63 drgnm07 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
64 seen07 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
65 dosage07 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
66 recd07 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
67 name08 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
68 stren08 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
69 drgnm08 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
70 seen08 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
71 dosage08 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
72 recd08 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
73 name09 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
74 stren09 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
75 drgnm09 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
76 seen09 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
77 dosage09 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
78 recd09 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
79 name10 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
80 stren10 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
81 drgnm10 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
82 seen10 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
83 dosage10 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
84 recd10 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
85 name11 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
86 stren11 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
87 drgnm11 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
88 seen11 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
89 dosage11 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
90 recd11 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
91 name12 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
92 stren12 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
93 drgnm12 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
94 seen12 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
95 dosage12 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
96 recd12 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
97 name13 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
98 stren13 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
99 drgnm13 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
100 seen13 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
101 dosage13 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
102 recd13 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
103 name14 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
104 stren14 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
105 drgnm14 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
106 seen14 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
107 dosage14 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
108 recd14 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
109 name15 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
110 stren15 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
111 drgnm15 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
112 seen15 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
113 dosage15 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
114 recd15 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
115 name16 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
116 stren16 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
117 drgnm16 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
118 seen16 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
119 dosage16 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
120 recd16 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
121 name17 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
122 stren17 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
123 drgnm17 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
124 seen17 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
125 dosage17 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
126 recd17 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
127 name18 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
128 stren18 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
129 drgnm18 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
130 seen18 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
131 dosage18 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
132 recd18 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
133 name19 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
134 stren19 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
135 drgnm19 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
136 seen19 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
137 dosage19 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
138 recd19 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
139 name20 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
140 stren20 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
141 drgnm20 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
142 seen20 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
143 dosage20 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
144 recd20 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
145 name21 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
146 stren21 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
147 drgnm21 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
148 seen21 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
149 dosage21 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
150 recd21 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
151 name22 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
152 stren22 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
153 drgnm22 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
154 seen22 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
155 dosage22 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
156 recd22 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
157 name23 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
158 stren23 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
159 drgnm23 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
160 seen23 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
161 dosage23 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
162 recd23 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
163 name24 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
164 stren24 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
165 drgnm24 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
166 seen24 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
167 dosage24 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
168 recd24 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
169 name25 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
170 stren25 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
171 drgnm25 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
172 seen25 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
173 dosage25 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
174 recd25 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
175 name26 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
176 stren26 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
177 drgnm26 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
178 seen26 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
179 dosage26 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
180 recd26 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
181 name27 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
182 stren27 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
183 drgnm27 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
184 seen27 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
185 dosage27 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
186 recd27 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
187 name28 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
188 stren28 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
189 drgnm28 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
190 seen28 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
191 dosage28 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
192 recd28 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
193 name29 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
194 stren29 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
195 drgnm29 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
196 seen29 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
197 dosage29 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
198 recd29 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
199 name30 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
200 stren30 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
201 drgnm30 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
202 seen30 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
203 dosage30 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
204 recd30 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
205 name31 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
206 stren31 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
207 drgnm31 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
208 seen31 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
209 dosage31 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
210 recd31 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
211 name32 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
212 stren32 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
213 drgnm32 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
214 seen32 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
215 dosage32 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
216 recd32 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
217 name33 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
218 stren33 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
219 drgnm33 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
220 seen33 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
221 dosage33 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
222 recd33 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
223 name34 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
224 stren34 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
225 drgnm34 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
226 seen34 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
227 dosage34 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
228 recd34 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
229 name35 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
230 stren35 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
231 drgnm35 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
232 seen35 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
233 dosage35 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
234 recd35 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
235 name36 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
236 stren36 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
237 drgnm36 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
238 seen36 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
239 dosage36 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
240 recd36 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
241 name37 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
242 stren37 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
243 drgnm37 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
244 seen37 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
245 dosage37 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
246 recd37 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
247 name38 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
248 stren38 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
249 drgnm38 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
250 seen38 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
251 dosage38 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
252 recd38 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
253 name39 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
254 stren39 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
255 drgnm39 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
256 seen39 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
257 dosage39 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
258 recd39 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
259 name40 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
260 stren40 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
261 drgnm40 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
262 seen40 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
263 dosage40 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
264 recd40 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
265 name41 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
266 stren41 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
267 drgnm41 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
268 seen41 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
269 dosage41 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
270 recd41 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
271 name42 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
272 stren42 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
273 drgnm42 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
274 seen42 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
275 dosage42 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
276 recd42 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
277 name43 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
278 stren43 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
279 drgnm43 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
280 seen43 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
281 dosage43 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
282 recd43 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
283 name44 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
284 stren44 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
285 drgnm44 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
286 seen44 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
287 dosage44 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
288 recd44 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
289 name45 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
290 stren45 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
291 drgnm45 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
292 seen45 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
293 dosage45 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
294 recd45 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
295 name46 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
296 stren46 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
297 drgnm46 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
298 seen46 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
299 dosage46 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
300 recd46 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
301 name47 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
302 stren47 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
303 drgnm47 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
304 seen47 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
305 dosage47 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
306 recd47 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
307 name48 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
308 stren48 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
309 drgnm48 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
310 seen48 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
311 dosage48 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
312 recd48 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
313 name49 a1. [INTERVIEWER: NAME OF MEDICINE] String[50]
314 stren49 a2. [INTERVIEWER: ENTER STRENGTH] String[10]
315 drgnm49 b. [INTERVIEWER: IS DRUG NAME FROM CONTAINER?] 1= Yes 2= No
316 seen49 c. [INTERVIEWER: IS DRUG SEEN?] 1= Yes 2= No
317 dosage49 d. On average, how many pills (capsules or other dosage units) did you take per day during the past two weeks? [CODE 66 IF TAKEN LESS THAN 01 PER DAY] 1 .. 66
318 recd49 e. [INTERVIEWER: ENTER NAME OF PHARMACY AND PRESCRIPTION NO. TYPE `OTC' IF MEDICINE IS NOT PRESCRIBED] String[40]
319 stroke MEDICAL HISTORY First I would like to ask you a few questions about specific medical conditions such as stroke and Parkinson's disease. STROKE 1. Have you EVER been told by a doctor, nurse or therapist that you had a STROKE, TRANSIENT ISCHEMIC ATTACK (TIA) or BRAIN HEMORRHAGE? 1= Yes 2= Suspect or possible 3= No
320 strokeyr 1a. When was the last time? [ENTER YEAR] [INTERVIEWER: `Last' refers to the most recent event.] 1940 .. 2020
321 faint0 At the time of this (last) event, did you you have . . . a. Fainting, blackout or loss of consciousness? 1= Yes 2= Suspect 3= No
322 dizzy0 b. Dizzyness or lightheadedness? 1= Yes 2= Suspect 3= No
323 memory0 c. Memory loss or forgetfulness? 1= Yes 2= Suspect 3= No
324 speech0 At the time of this (last) event, did you you have . . . d. Language or speech change? 1= Yes 2= Suspect 3= No
325 vision0 e. Loss of vision? 1= No 2= right only 3= left only 4= both
326 face0 f. Weakness or paralysis of your face? 1= No 2= right only 3= left only 4= both
327 weaklim0 g. Weakness or paralysis of your arms or legs? 1= No 2= right only 3= left only 4= both
328 limsens0 h. Loss or change of sensation in your arms or legs? 1= No 2= right only 3= left only 4= both
329 sympspe0 i. Specify any other signs or symptoms associated with this (last) event? String[40]
330 sametim0 j. Did the stroke occur around the same time as a SURGICAL OPERATION, HEART ATTACK, BREATHING DIFFICULTY, or ANOTHER SERIOUS MEDICAL PROBLEM? 1= Yes 2= Suspect 3= No
331 samespe0 Specify: String[60]
332 inhosp 2. Have you EVER been HOSPITALIZED OVERNIGHT or longer because of a STROKE, a TIA or a BRAIN HEMORRHAGE? 1= Yes 2= Suspect 3= No
333 prompt1 2a. Was this the same event we just spoke about? 1= Yes 2= No
334 hospyear When was the last time? [ENTER YEAR] [INTERVIEWER: `Last' refers to the most recent hospitalization event.] 1940 .. 2020
335 hospname 2b. What was the name of the hospital? String[30]
336 faint1 At the time of this (last) event, did you you have . . . a. Fainting, blackout or loss of consciousness? 1= Yes 2= Suspect 3= No
337 dizzy1 b. Dizzyness or lightheadedness? 1= Yes 2= Suspect 3= No
338 memory1 c. Memory loss or forgetfulness? 1= Yes 2= Suspect 3= No
339 speech1 At the time of this (last) event, did you have . . . [INTERVIEWER: `Last' refers to the most recent hospitalization event.] d. Language or speech change? 1= Yes 2= Suspect 3= No
340 vision1 e. Loss of vision? 1= No 2= right only 3= left only 4= both
341 face1 f. Weakness or paralysis of your face? 1= No 2= right only 3= left only 4= both
342 weaklim1 g. Weakness or paralysis of your arms or legs? 1= No 2= right only 3= left only 4= both
343 limsens1 h. Loss or change of sensation in your arms or legs? 1= No 2= right only 3= left only 4= both
344 sympspe1 i. Specify any other signs or symptoms associated with this (last) event? String[40]
345 sametim1 j. Did the stroke occur around the same time as a SURGICAL OPERATION, HEART ATTACK, BREATHING DIFFICULTY, or ANOTHER SERIOUS MEDICAL PROBLEM? 1= Yes 2= Suspect 3= No
346 samespe1 Specify: String[60]
347 strokscn 3. Have you EVER had a CT, MRI or other type of brain scan because of a STROKE, a TIA or a BRAIN HEMORRHAGE? 1= Yes 2= Suspect 3= No
348 prompt2 3a. Was this for ^event we just spoke about? 1= Yes 2= No
349 scanyear When was the last time? [ENTER YEAR] [INTERVIEWER: `Last' refers to the most recent scan.] 1940 .. 2020
350 scanloc 3b. What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? String[30]
351 faint2 At the time of this (last) event, did you you have . . . a. Fainting, blackout or loss of consciousness? 1= Yes 2= Suspect 3= No
352 dizzy2 b. Dizzyness or lightheadedness? 1= Yes 2= Suspect 3= No
353 memory2 c. Memory loss or forgetfulness? 1= Yes 2= Suspect 3= No
354 speech2 d. Language or speech change? 1= Yes 2= Suspect 3= No
355 vision2 e. Loss of vision? 1= No 2= right only 3= left only 4= both
356 face2 f. Weakness or paralysis of your face? 1= No 2= right only 3= left only 4= both
357 weaklim2 g. Weakness or paralysis of your arms or legs? 1= No 2= right only 3= left only 4= both
358 limsens2 h. Loss or change of sensation in your arms or legs? 1= No 2= right only 3= left only 4= both
359 sympspe2 i. Specify any other signs or symptoms associated with this (last) event? String[40]
360 sametim2 j. Did the stroke occur around the same time as a SURGICAL OPERATION, HEART ATTACK, BREATHING DIFFICULTY, or ANOTHER SERIOUS MEDICAL PROBLEM? 1= Yes 2= Suspect 3= No
361 samespe2 Specify: String[60]
362 multiple 4. Did you have only ONE STROKE, TIA or BRAIN HEMORRHAGE, or more than one? 1= Only one 2= More than one
363 leftspec 5. Specify leftover troubles from your stroke(s)? String[60]
364 everscan 6. Have you EVER had a CT, MRI or other type of brain scan? 1= Yes 2= Suspect 3= No
365 reason 6c. Reason String[60]
366 escanloc 6d. What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? String[30]
367 parks 1. Have you EVER been told by a doctor, nurse or therapist that you had PARKINSONISM or PARKINSON'S DISEASE? 1= Yes 2= Suspect or possible 3= No
368 year 1a. When were you first told this? 1940 .. 2020
369 gait With the parkinsonism, did you have . . . 2. Shuffling or unsteady gait, or loss of balance? 1= Yes 2= Suspect 3= No
370 writing 3. A change in your handwriting? 1= Yes 2= Suspect 3= No
371 stiff 4. Stiffness or rigidity of your arms or legs? 1= No 2= right only 3= left only 4= both
372 slowmove 5. Slowness of movement of your arms, hands or legs? 1= No 2= right only 3= left only 4= both
373 tremor 6. Tremor of your hands or feet? 1= No 2= right only 3= left only 4= both
374 medicate 7. Are you currently taking any medication for your parkinsonism or Parkinson's disease (some examples are Sinemet, Symmetrel, Parlodel, Bromocriptine, etc.)? 1= Yes 2= Suspect or possible 3= No
375 medspec 7a. Specify String[30]
376 histad Have you ever been told by a doctor, nurse, or therapist that you had dementia, senility, or Alzheimer's disease? 1= Yes 2= Suspect 3= No
377 respqs Will MEP/MIP data be entered directly into Blaise form? 1= Yes 2= No
378 expir1 EXPIRATORY RESPIRATORY PRESSURE TESTING [Use the Expiratory Respiratory Pressure Valve for the Micro MPM.] [Reset to 0. Enter 995.5 for tried, but unable.] MEP trial 1 ________ cm H20 1.0 .. 995.5
379 expir2 [Reset to 0. Enter 995.5 for tried, but unable.] MEP trial 2 ________ cm H20 1.0 .. 995.5
380 inspir1 INSPIRATORY RESPIRATORY PRESSURE TESTING [Use the Inspiratory Respiratory Pressure Valve for the Micro MPM.] [Reset to 0. Enter 995.5 for tried, but unable.] MIP trial 1 ________ cm H20 1.0 .. 995.5
381 inspir2 [Reset to 0. Enter 995.5 for tried, but unable.] MIP trial 2 ________ cm H20 1.0 .. 995.5
382 mepmipcm MEP/MIP Enter any comments. [Press enter to continue if none.] String[250]
383 spiroqs Will spirometry data be entered directly into Blaise form? 1= Yes 2= No
384 fev11 RESET Spirometry device FEV1 Trial 1 [Enter 95.5 for tried but unable.] _____ liters 0.00 .. 95.50
385 pvc1 PVC Trial 1 _____ liters 0.00 .. 10.00
386 fer1 FER Trial 1 _____ percent 0 .. 100
387 pef1 PEF Trial 1 _____ liters/minute [If greater than 999, enter 999.] 0 .. 999
388 fev12 RESET Spirometry device FEV1 Trial 2 [Enter 95.5 for tried but unable.] _____ liters 0.00 .. 95.50
389 pvc2 PVC Trial 2 _____ liters 0.00 .. 10.00
390 fer2 FER Trial 2 _____ percent 0 .. 100
391 pef2 PEF Trial 2 _____ liters/minute [If greater than 999, enter 999.] 0 .. 999
392 spcom Spirometry Enter any comment. [Press enter to continue if none.] String[250]
393 q8atap FINGER TAPPING [DEPRESS BUTTON UNTIL '--' APPEARS.] 1. Right index finger. 'I want to see how quickly you can tap this key. When I tell you to begin, tap this key as quickly as you can until I tell you to stop.' Record first trial. ______Taps completed in 10 seconds. 97 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 1 .. 97
394 q8ana Specify reason. String[40]
395 q8btap FINGER TAPPING [RESET TAPPER] Left index finger. Record first trial. ______Taps completed in 10 seconds. 97 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 1 .. 97
396 q8bna Specify reason. String[40]
397 q8ctap FINGER TAPPING [RESET TAPPER] Right index finger. Record second trial. ______Taps completed in 10 seconds. 97 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 1 .. 97
398 q8cna Specify reason. String[40]
399 q8dtap FINGER TAPPING [RESET TAPPER] Left index finger. Record second trial. ______Taps completed in 10 seconds. 97 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 1 .. 97
400 q8dna Specify reason. String[40]
401 rhand1 HAND DYNAMOMETRY [SET RED NEEDLE TO 0.] 'I want to see how strongly you can squeeze this handle. When I say go, squeeze the handle as hard as you can until I tell you to stop.' Right Hand Trial 1 [RECORD IN POUNDS.] 777 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 0 .. 777
402 rhand1na Specify reason. String[40]
403 lhand1 HAND DYNAMOMETRY [RESET NEEDLE TO 0.] Left Hand Trial 1 [RECORED IN POUNDS]. 777 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 0 .. 777
404 lhand1na Specify reason. String[40]
405 rhand2 HAND DYNAMOMETRY [RESET NEEDLE TO 0.] Right Hand Trial 2 [RECORD IN POUNDS]. 777 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 0 .. 777
406 rhand2na Specify reason. String[40]
407 lhand2 HAND DYNAMOMETRY [RESET NEEDLE TO 0.] Left Hand Trial 2 [RECORD IN POUNDS]. 777 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 0 .. 777
408 lhand2na Specify reason. String[40]
409 rthand1 PINCH DYNAMOMETRY [SET RED NEEDLE TO 0.] 'I want to see how strongly you can pinch this plate. When I say go, squeeze the plate as hard as you can until I tell you to stop.' Right Hand Trial 1 [RECORD IN POUNDS]. 77 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 0 .. 77
410 rthand1n Specify reason. String[40]
411 lthand1 PINCH DYNAMOMETRY [RESET NEEDLE TO 0.] Left Hand Trial 1 [RECORD IN POUNDS]. 77 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 0 .. 77
412 lthand1n Specify reason. String[40]
413 rthand2 PINCH DYNAMOMETRY [RESET NEEDLE TO 0.] Right Hand Trial 2 [RECORD IN POUNDS]. 77 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 0 .. 77
414 rthand2n Specify reason. String[40]
415 lthand2 PINCH DYNAMOMETRY [RESET NEEDLE TO 0.] Left Hand Trial 2 [RECORD IN POUNDS]. 77 : Tried but unable, Specify reason________________________ ] Don't Know, Specify reason________________________ ] Refusal - Not Attempted, Specify reason________________________ ] 0 .. 77
416 lthand2n Specify reason. String[40]
417 nasorest NEUROLOGICAL EXAMINATION The neurologic examination should begin with both the subject and examiner comfortably seated facing one another. Right and left are always referenced to the subject. FACIAL STRENGTH [EXAMINER: Observe facial symmetry at rest and with activation of facial muscle groups. Ask subject to raise eyebrows, close eyes, smile.] 1. Nasolabial fold at rest and or action 1= Symmetric 2= Right flatter than left 3= Left flatter than right 7= Unable to test
418 fissures 2. Palpebral fissures 1= Symmetric 2= Right wider than left 3= Left wider than right 7= Unable to test
419 rightsup VISUAL FIELDS [EXAMINER: Test each quadrant separately by confrontation with both eyes open. Wiggle fingers in the middle of each quadrant for one second and ask the subject to look at the fingers. If the subject is unable to comply, note whether the subject attends the wiggling fingers.] 1. Right superior quadrant 1= No visual field defect 2= Possible visual field defect 3= Definite visual field defect 7= Unable to test
420 rightinf 2. Right inferior quadrant 1= No visual field defect 2= Possible visual field defect 3= Definite visual field defect 7= Unable to test
421 leftsup 3. Left superior quadrant 1= No visual field defect 2= Possible visual field defect 3= Definite visual field defect 7= Unable to test
422 leftinf 4. Left inferior quadrant 1= No visual field defect 2= Possible visual field defect 3= Definite visual field defect 7= Unable to test
423 rarmrest RESTING TREMOR [EXAMINER: Instruct the subject to sit completely relaxed and to count aloud backwards from 10. Observe the hands and feet for rhythmic tremor.] 1. Right arm rest tremor 1= Absent 2= Possible rest tremor 3= Slight and infrequently present 4= Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present 5= Moderate in amplitude and present most of the time 6= Marked in amplitude and present most of the time 7= Unable to test 8= Unable to determine
424 larmrest 2. Left arm rest tremor 1= Absent 2= Possible rest tremor 3= Slight and infrequently present 4= Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present 5= Moderate in amplitude and present most of the time 6= Marked in amplitude and present most of the time 7= Unable to test 8= Unable to determine
425 rlegrest 3. Right leg rest tremor 1= Absent 2= Possible rest tremor 3= Slight and infrequently present 4= Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present 5= Moderate in amplitude and present most of the time 6= Marked in amplitude and present most of the time 7= Unable to test 8= Unable to determine
426 llegrest 4. Left leg rest tremor 1= Absent 2= Possible rest tremor 3= Slight and infrequently present 4= Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present 5= Moderate in amplitude and present most of the time 6= Marked in amplitude and present most of the time 7= Unable to test 8= Unable to determine
427 chinjaw 5. Chin/jaw rest tremor 1= Absent 2= Possible rest tremor 3= Slight and infrequently present 4= Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present 5= Moderate in amplitude and present most of the time 6= Marked in amplitude and present most of the time 7= Unable to test 8= Unable to determine
428 rhanddys FINGER-TO-FINGER [EXAMINER: Instruct the subject to touch his or her index finger to your finger. The subject should extend the arm completely. Observe for dysmetria and action tremor. Score action tremor in next question.] 1. Right hand 1= No dysmetria 2= Possible dysmetria 3= Definite dysmetria 4= Unable to assess due to weakness 7= Unable to test
429 lhanddys 2. Left hand 1= No dysmetria 2= Possible dysmetria 3= Definite dysmetria 4= Unable to assess due to weakness 7= Unable to test
430 rhandact POSTURAL/ACTION TREMOR OF HANDS [EXAMINER: Instruct the subject to hold his or her arms perpendicular to body with the palms down and fingers spread apart for 10 seconds. Observe for postural tremor. Score both action and postural tremors. Record most severe tremor.] 3. Right hand 1= Absent 2= Possible 3= Present 4= Unable to test due to weakness
431 rhamp 3a. Amplitude 1= Slight 2= Mild 3= Moderate 4= Marked
432 rhaorp 3b. Posture/Action 1= Action only 2= Posture only 3= Action AND posture
433 rhfreq 3c. Frequency 1= Slow [<7 Hz] 2= Moderate [7-10 Hz] 3= Fast [>10 Hz]
434 lhandact 4. Left hand 1= Absent 2= Possible 3= Present 4= Unable to test due to weakness
435 lhamp 4a. Amplitude 1= Slight 2= Mild 3= Moderate 4= Marked
436 lhaorp 4b. Posture/Action 1= Action only 2= Posture only 3= Action AND posture
437 lhfreq 4c. Frequency 1= Slow [<7 Hz] 2= Moderate [7-10 Hz] 3= Fast [>10 Hz]
438 scptrem 0 .. 8
439 scrtrem 0 .. 30
440 ilptrem String[6]
441 ilrtrem String[6]
442 mposttrm 0 .. 2
443 mresttrm 0 .. 5
444 tapintro BRADYKINESIA Finger taps [EXAMINER: Subject taps thumb with index finger in rapid succession with widest amplitude possible for 10 seconds. Observe amplitude and speed of movement.] [Press enter to continue.] String[1]
445 rfingtap BRADYKINESIA-Finger taps 1. Right 1= Normal 2= Slowing OR reduction in amplitude which could be normal 3= Mild slowing AND reduction in amplitude 4= Moderately impaired. Definite early fatiguing. May have occasional arrests in movement. 5= Severely impaired. Frequent hesitation in initiating movements. 6= Can barely perform the task. 7= Unable to test.
446 lfingtap BRADYKINESIA-Finger taps 2. Left 1= Normal 2= Slowing OR reduction in amplitude which could be normal 3= Mild slowing AND reduction in amplitude 4= Moderately impaired. Definite early fatiguing. May have occasional arrests in movement. 5= Severely impaired. Frequent hesitation in initiating movements. 6= Can barely perform the task. 7= Unable to test.
447 rfist Fist clench [EXAMINER: Subject opens and closes fist as widely and as rapidly as possible for 10 seconds. Observe for speed and amplitude of movement.] 3. Right 1= Normal 2= Slowing OR reduction in amplitude which could be normal 3= Mild slowing AND reduction in amplitude 4= Moderately impaired. Definite early fatiguing. May have occasional arrests in movement. 5= Severely impaired. Frequent hesitation in initiating movements. 6= Can barely perform the task. 7= Unable to test.
448 lfist 4. Left 1= Normal 2= Slowing OR reduction in amplitude which could be normal 3= Mild slowing AND reduction in amplitude 4= Moderately impaired. Definite early fatiguing. May have occasional arrests in movement. 5= Severely impaired. Frequent hesitation in initiating movements. 6= Can barely perform the task. 7= Unable to test.
449 rprosup Pronation-Supination [EXAMINER: Instruct subject to alternately tap the front and back of his or her hand on his or her knee for 10 seconds. Observe for speed, amplitude and rhythmicity of movement.] 5. Right 1= Normal 2= Slowing OR reduction in amplitude which could be normal 3= Mild slowing AND reduction in amplitude 4= Moderately impaired. Definite early fatiguing. May have occasional arrests in movement. 5= Severely impaired. Frequent hesitation in initiating movements. 6= Can barely perform the task. 7= Unable to test.
450 lprosup 6. Left 1= Normal 2= Slowing OR reduction in amplitude which could be normal 3= Mild slowing AND reduction in amplitude 4= Moderately impaired. Definite early fatiguing. May have occasional arrests in movement. 5= Severely impaired. Frequent hesitation in initiating movements. 6= Can barely perform the task. 7= Unable to test.
451 rheeltap Leg agility [EXAMINER: Subject taps heel on ground in rapid succession for 10 seconds. Picks up entire leg. Amplitude should be about three inches.] 7. Right heel tap 1= Normal 2= Slowing OR reduction in amplitude which could be normal 3= Mild slowing AND reduction in amplitude 4= Moderately impaired. Definite early fatiguing. May have occasional arrests in movement. 5= Severely impaired. Frequent hesitation in initiating movements. 6= Can barely perform the task. 7= Unable to test.
452 lheeltap 8. Left heel tap 1= Normal 2= Slowing OR reduction in amplitude which could be normal 3= Mild slowing AND reduction in amplitude 4= Moderately impaired. Definite early fatiguing. May have occasional arrests in movement. 5= Severely impaired. Frequent hesitation in initiating movements. 6= Can barely perform the task. 7= Unable to test.
453 scbrady 0 .. 70
454 ilbrady String[6]
455 mbrady 0 .. 8
456 rarm STRENGTH [EXAMINER: When testing strength, push or pull for 2 seconds] Arm strength [EXAMINER: Instruct the subject to sit with both arms extended in front of the body with the palms facing upward and the fingers spread apart for 10 seconds. Observe for weakness and asymmetry.] 1. Right arm drift *******NOTE: BE SURE YOU ARE CODING EVERYTHING ACCORDING TO THE >>SUBJECT'S<< RIGHT OR LEFT SIDE. 1= No weakness 2= Possible weakness 3= Definite weakness, but elevates arm 10 seconds 4= Elevates arm less than 10 seconds 5= Unable to elevate arm 7= Unable to test
457 larm 2. Left arm drift 1= No weakness 2= Possible weakness 3= Definite weakness, but elevates arm 10 seconds 4= Elevates arm less than 10 seconds 5= Unable to elevate arm 7= Unable to test
458 armsym 3. Arm drift symmetric 1= Yes 2= Right weaker than left 3= Left weaker than right 7= Unable to test
459 neckrig HYPERTONICITY [EXAMINER: Judged on passive movement of the extremities with subject relaxed in a sitting position.] 1. Neck Rigidity 1= Absent 2= Slight, questionably present 3= Mild to moderate 4= Marked, but full range of motion achieved easily 5= Severe, full range of motion achieved with difficulty 7= Unable to test
460 neckcog 1a. Cogwheeling 1= Yes 2= Suspect 3= No 7= Unable to test
461 rarmrig 2. Right arm rigidity present in flexors AND extensors 1= Absent 2= Slight, questionably present 3= Mild to moderate 4= Marked, but full range of motion achieved easily 5= Severe, full range of motion achieved with difficulty 7= Unable to test
462 rarmcog 2a. Cogwheeling 1= Yes 2= Suspect 3= No 7= Unable to test
463 rarmspas 3. Spasticity. 1= Yes 2= Suspect 3= No 7= Unable to test
464 larmrig 5. Left arm rigidity present in flexors AND extensors 1= Absent 2= Slight, questionably present 3= Mild to moderate 4= Marked, but full range of motion achieved easily 5= Severe, full range of motion achieved with difficulty 7= Unable to test
465 larmcog 5a. Cogwheeling 1= Yes 2= Suspect 3= No 7= Unable to test
466 larmspas 6. Spasticity. 1= Yes 2= Suspect 3= No 7= Unable to test
467 rlegrig 8. Right leg rigidity present in flexors AND extensors 1= Absent 2= Slight, questionably present 3= Mild to moderate 4= Marked, but full range of motion achieved easily 5= Severe, full range of motion achieved with difficulty 7= Unable to test
468 rlegcog 8a. Cogwheeling 1= Yes 2= Suspect 3= No 7= Unable to test
469 rlegspas 9. Spasticity. 1= Yes 2= Suspect 3= No 7= Unable to test
470 llegrig 11. Left leg rigidity present in flexors AND extensors 1= Absent 2= Slight, questionably present 3= Mild to moderate 4= Marked, but full range of motion achieved easily 5= Severe, full range of motion achieved with difficulty 7= Unable to test
471 llegcog 11a. Cogwheeling 1= Yes 2= Suspect 3= No 7= Unable to test
472 llegspas 12. Spasticity. 1= Yes 2= Suspect 3= No 7= Unable to test
473 scrigid 0 .. 25
474 ilrigid String[6]
475 mrigid 0 .. 5
476 rbiceps DEEP TENDON REFLEXES 1. Right Biceps 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 5= Possibly increased 6= Definitely increased 7= Unable to test
477 lbiceps 2. Left Biceps 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 5= Possibly increased 6= Definitely increased 7= Unable to test
478 bicepsym 3. Biceps symmetric 1= Yes 2= Right greater than left 3= Left greater than right 7= Unable to test
479 rtriceps 7. Right Triceps 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 5= Possibly increased 6= Definitely increased 7= Unable to test
480 ltriceps 8. Left Triceps 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 5= Possibly increased 6= Definitely increased 7= Unable to test
481 tricpsym 9. Triceps symmetric 1= Yes 2= Right greater than left 3= Left greater than right 7= Unable to test
482 rpatella 10. Right Patella 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 5= Possibly increased 6= Definitely increased 7= Unable to test
483 lpatella 11. Left Patella 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 5= Possibly increased 6= Definitely increased 7= Unable to test
484 patelsym 12. Patella symmetric 1= Yes 2= Right greater than left 3= Left greater than right 7= Unable to test
485 rachill 13. Right achilles 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 5= Possibly increased 6= Definitely increased 7= Unable to test
486 lachill 14. Left achilles 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 5= Possibly increased 6= Definitely increased 7= Unable to test
487 achilsym 15. Achilles symmetric 1= Yes 2= Right greater than left 3= Left greater than right 7= Unable to test
488 rbigtoe BABINSKI SIGN 1. Right big toe 1= Normal 2= Possible 3= Present 7= Unable to test
489 lbigtoe 2. Left big toe 1= Normal 2= Possible 3= Present 7= Unable to test
490 bmd1 Clinical Bone Sonometer Bone Mineral Density (BMD) Trial 1 _____ g/cm2 [Enter 7 for tried but unable.] 0.000 .. 7.000
491 tscore1 Trial 1 Record T score ______ -5.0 .. 4.0
492 qui1 Trial 1 Record Quality Ultrasound Index (QUI)/stiffness _____ -50.0 .. 200.0
493 bua1 Trial 1 Record broad band ultrasound attenuation (BUA) _____dB/MHz 0.0 .. 200.0
494 sos1 Trial 1 Record speed of sound (SOS) _____ m/sec 800.0 .. 2500.0
495 soncom Clinical Bone Sonometer- Check scores and make comments. Bone Mineral Density(BMD)** ^bmd1 T score******************** ^tscore1 QUI/stiffness************** ^qui1 BUA************************ ^bua1 SOS************************ ^sos1 Page up and re-enter if any values are not correct. Enter any comments.[Press enter to continue if none.] String[250]
496 rtoevib SENSORY FUNCTION Vibratory sensation 1. Right big toe [EXAMINER: First, make sure that subject understands the sensation. Tap tuning fork in palm of hand and test for ability to perceive vibration on the top of the large toe of each foot.] 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 7= Unable to test
497 ltoevib Vibratory sensation 2. Left big toe 1= Normal 2= Possibly reduced 3= Definitely reduced 4= Absent 7= Unable to test
498 rlegvib Stocking pattern of vibratory loss 3. Right Leg. [EXAMINER: Determine whether there is a greater sensory loss in the toe vs. the ankle] 1= Yes 2= Possible 3= No
499 ltlegvib Stocking pattern of vibratory loss 4. Left leg. [EXAMINER: Determine whether there is a greater sensory loss in the toe vs. the ankle] 1= Yes 2= Possible 3= No
500 hpinsym Pin sensation 1. Back of index fingers symmetric 1= Yes 2= Right with less sensation than left 3= Left with less sensation than right 7= Unable to test
501 rhandpin Pin sensation 2. Right Index vs. Pinky [EXAMINER: Now instruct the subject that you will test the sensation of the index and pinky fingers. Ask the subject to tell you whether they feel the same; if they are different, where does he or she feel it more, the index finger or the small finger.] 1= Same 2= Index possible more than pinky 3= Index definitely more than pinky 4= Pinky possibly more than index 5= Pinky definitely more than index
502 lhandpin Pin sensation 3. Left Index vs. Pinky 1= Same 2= Index possible more than pinky 3= Index definitely more than pinky 4= Pinky possibly more than index 5= Pinky definitely more than index
503 fpinsym Pin sensation 4. Top of big toe symmetric 1= Yes 2= Right with less sensation than left 3= Left with less sensation than right 7= Unable to test
504 rlegpin Stocking pattern of pin loss 5. Right Leg. [EXAMINER: Tell the subject that he or she will feel the pin on the toe and ankle. Determine whether it is the same or different -- consistent with a stocking pattern of sensory loss.] 1= Yes 2= Possible 3= No
505 ltlegpin Stocking pattern of pin loss 6. Left leg. 1= Yes 2= Possible 3= No
506 rarmabd1 Nicholas MMT [CHECK CALIBRATION OR RESET INTSTRUMENT 1. Right arm abduction [DELTOID] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
507 larmabd1 2. Left arm abduction [DELTOID] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
508 rarmabd2 3. Right arm abduction [DELTOID] Trial 2 - Enter 95.5 for tried, but unable 0.1 .. 95.5
509 larmabd2 4. Left arm abduction [DELTOID] Trial 2 - Enter 95.5 for tried, but unable 0.1 .. 95.5
510 rarmflx1 Right arm flexion [BICEPS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
511 larmflx1 Left arm flexion [BICEPS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
512 rarmext1 Right arm extension [TRICEPS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
513 larmext1 Left arm extension [TRICEPS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
514 rhipflx1 5. Right hip flexion [ILIOPSOAS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
515 lhipflx1 6. Left hip flexion [ILIOPSOAS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
516 rhipflx2 7. Right hip flexion [ILIOPSOAS] Trial 2 - Enter 95.5 for tried, but unable 0.1 .. 95.5
517 lhipflx2 8. Left hip flexion [ILIOPSOAS] Trial 2 - Enter 95.5 for tried, but unable 0.1 .. 95.5
518 rlegext1 9. Right leg extension [QUADRICEPS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
519 llegext1 10. Left leg extension [QUADRICEPS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
520 rfotflx1 13. Right foot plantar flexion [GASTROCNEMIUS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
521 lfotflx1 14. Left foot plantar flexion [GASTROCNEMIUS] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
522 rfotflx2 15. Right foot plantar flexion [GASTROCNEMIUS] Trial 2 - Enter 95.5 for tried, but unable 0.1 .. 95.5
523 lfotflx2 16. Left foot plantar flexion [GASTROCNEMIUS] Trial 2 - Enter 95.5 for tried, but unable 0.1 .. 95.5
524 rfotdor1 Right foot dorsiflexion [TIBIALIS ANTERIOR] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
525 lfotdor1 Left foot dorsiflexion [TIBIALIS ANTERIOR] Trial 1 - Enter 95.5 for tried, but unable 0.1 .. 95.5
526 rfotdor2 Right foot dorsiflexion [TIBIALIS ANTERIOR] Trial 2 - Enter 95.5 for tried, but unable 0.1 .. 95.5
527 lfotdor2 Left foot dorsiflexion [TIBIALIS ANTERIOR] Trial 2 - Enter 95.5 for tried, but unable 0.1 .. 95.5
528 muscls01 17. List all muscles you were unable to break 1= Right Deltoid 2= Left Deltoid 3= Right Bicep 4= Left Bicep 5= Right Tricep 6= Left Tricep 7= Right Hip Flexion 8= Left Hip Flexion 9= Right Leg Extension 10= Left Leg Extension 11= Right Plantar Flexion 12= Left Plantar Flexion 13= Right Dorsiflexion 14= Left Dorsiflexion 15= N/A
529 muscls02 17. List all muscles you were unable to break See previous question
530 muscls03 17. List all muscles you were unable to break See previous question
531 muscls04 17. List all muscles you were unable to break See previous question
532 muscls05 17. List all muscles you were unable to break See previous question
533 muscls06 17. List all muscles you were unable to break See previous question
534 muscls07 17. List all muscles you were unable to break See previous question
535 muscls08 17. List all muscles you were unable to break See previous question
536 muscls09 17. List all muscles you were unable to break See previous question
537 muscls10 17. List all muscles you were unable to break See previous question
538 muscls11 17. List all muscles you were unable to break See previous question
539 muscls12 17. List all muscles you were unable to break See previous question
540 muscls13 17. List all muscles you were unable to break See previous question
541 muscls14 17. List all muscles you were unable to break See previous question
542 mmtcom Nicholas MMT Enter any comments. [Press enter to continue if none.] String[250]
543 chairup POSTURE/GAIT 1. Arising from a chair [EXAMINER: Seat the subject in a straight back chair with arms. Instruct him or her to cross his or her arms across his or her chest, and to stand from the chair. If he or she is unable to do this, he or she may stand using his or her hands.] 1= Normal 2= Slow, could be normal 3= Needs more than 1 attempt, but does not push with arms 4= Pushes self up from arms of chair 5= Using arms, tends to fall back or requires more than one attempt, but able to stand without help 6= Unable to arise without help 7= Unable to test
544 basegait Gait [EXAMINER: Ask the subject to walk as fast as possible (about 10 feet), turn around and walk back. Observe speed, associated movements and base.] 2. Base 1= Normal, medial malleoli within 3 inches 2= Slightly widened, medial malleoli 3-6 inches apart 3= Widened, medial melleoli > 6 inches apart 7= Unable to test
545 shufgait 3. Shuffling Gait [EXAMINER: Loss of heel-toe walk with low foot clearance.] 1= None 2= Walks slowly, may take short steps. Could be normal 3= Walks slowly, shuffles, no festination or propulsion 4= Walks with difficulty, shuffles, may festinate or propulse, requires no assistance 5= Severe disturbance of gait, shuffles, may festinate or propulse, unable to ambulate without assistance 6= Cannot walk at all due to shuffling gait, not even with assistance
546 armswing 3a. Reduced Armswing 1= Yes 2= Suspect 3= No 7= Unable to test
547 armside 3b. On which side is the armswing reduced? 1= Right 2= Left 3= Both
548 legcirc 4. Circumduction of Leg 1= Yes 2= Suspect 3= No 7= Unable to test
549 legside 4a. On which side is this? 1= Right 2= Left 3= Both
550 body 5. Body bradykinesia/hypokinesia [EXAMINER: This item represents a global view of the slowness and deliberateness of the subject's movements. During the examination, observe the rapidity of movements, also observe decrease in armswing and spontaneous movements.] 1= None 2= Minimal slowness, giving movement a deliberate character, possibly reduced amplitude 3= Mild degree of slowness and poverty of movement which is definitely abnormal, alternatively, some reduced amplitude 4= Moderate slowness, poverty or small amplitude of movement 5= Marked slowness, poverty or small amplitude of movement
551 turning 6. Turning 1= Pivots on narrow base 2= Hesitates or widens base, but steady 3= Turns slowly and awkwardly 4= Would likely fall without aid 5= Cannot turn 7= Unable to test
552 gaitspec 10. Other gait abnormality [Press enter to continue if none.] String[40]
553 posture 1. Posture [EXAMINER: View the subject from the front and from the side.] 1= Normal erect 2= Slightly stooped posture, could be normal 3= Moderately stooped, can be leaning slightly to one side 4= Severely stooped with kyphosis, can be moderately leaning to one side 5= Marked flexion with extreme abnormality of posture 7= Unable to test
554 introstb 2. Postural Stability [EXAMINER: Instruct the subject to stand with the feet about 6 inches apart. Instruct him or her that you will be pulling back on his or her shoulders and that he or she should `try not to fall.' Standing behind the subject, pull on the shoulders with increasing strength until the subject loses his or her balance. Note the number of steps and the strength of the pull.] [PRESS ENTER TO SCORE.] String[1]
555 stblpost 2. Postural Stability 1= Normal, takes 1 step to correct balance 2= Possible retropulsion, takes 2 steps to correct balance 3= Definite retropulsion, takes 3 or more steps, but recovers unaided 4= Would fall if not caught 5= Unstable, tends to lose balance spontaneously 6= Unable to stand without assistance
556 numsteps 2a. NUMBER OF STEPS 3 .. 20
557 pull 2b. Strength of pull 1= Very light pull 2= Mild to moderate pull 3= Moderate to strong pull 4= Strong pull
558 screflex 0 .. 35
559 ilreflex String[6]
560 mreflex 0 .. 6
561 bedtime Sleep Questionnaire 1. During the past month, when have you usually gone to bed at night? Time (hh:mm) [INTERVIEWER If P responds with a range of time for bedtime, take the average. For example, if P indicates a bedtime between 10:30 pm-11:00 pm, enter 10:45 pm as the average bedtime. ] String[5]
562 bedtime_ 1. During the past month, when have you usually gone to bed at night? 1a. [am/pm] String[2]
563 min2slee 2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night? [Number of minutes] [INTERVIEWER If P responds with a range of minutes, take the average.] 0 .. 999
564 getuptim 3. During the past month, when have you usually gotten up in the morning? Time (hh:mm) [INTERVIEWER If P responds with a range of time for getting up time, take the average. ] String[5]
565 getupti2 3. During the past month, when have you usually gotten up in the morning? 3a. [am/pm] String[2]
566 sleephrs 4. During the past month, how many hours did you usually sleep at night? [hours] [INTERVIEWER If P responds with a range of time, take the average. ] 0 .. 23
567 sleephr2 4. During the past month, how many hours did you usually sleep at night? 4a. [minutes] 0 .. 59
568 trsleep_ 5. How often do you have trouble falling asleep? 1= Never 2= Rarely 3= Sometimes 4= Often 5= Very often
569 trsleep3 6. During the past month, how often did you have trouble falling asleep within 30 minutes? 1= Not at all 2= Less than once a week 3= Once or twice a week 4= Three or more times a week 5= Nearly every day
570 wakenigh 7. How often are you troubled by waking up during the night? 1= Never 2= Rarely 3= Sometimes 4= Often 5= Very often
571 wakenig2 8. During the past month, how often did you wake up in the middle of the night or early morning? 1= Not at all 2= Less than once a week 3= Once or twice a week 4= Three or more times a week 5= Nearly every day
572 rested_f 9. How often do you feel really rested when you wake up in the morning? 1= Never 2= Rarely 3= Sometimes 4= Often 5= Very often
573 tiredaft 10. During the past month, how often have you felt tired or fatigued after sleep? 1= Not at all 2= Less than once a week 3= Once or twice a week 4= Three or more times a week 5= Nearly every day
574 tiredwak 11. In the past month, during your waking time, how often have you felt tired, fatigued or not up to par? 1= Not at all 2= Less than once a week 3= Once or twice a week 4= Three or more times a week 5= Nearly every day
575 nap_freq 12. How often do you get so sleepy during the day or evening that you have to take a nap? 1= Never 2= Rarely 3= Sometimes 4= Often 5= Very often
576 sleepdri 13. Have you ever nodded off or fallen asleep while driving a vehicle? 0= No 1= Yes
577 sleepdr2 13a. Over the past month, how often has this occurred? 1= Not at all 2= Less than once a week 3= Once or twice a week 4= Three or more times a week 5= Nearly every day
578 psqi_med 14. Have you used sleeping medications in two weeks prior to this interview? 0= No 1= Yes
579 snore 15. Do you snore? 0= No 1= Yes 9= Don't know
580 snorebot 15a. Has your snoring ever bothered other people? 0= No 1= Yes 9= Don't know
581 snorerat 15b. If you snore, would you say your snoring is _____ ? 1= Slightly louder than breathing 2= As loud as talking 3= Louder than talking 4= Very loud - can be heard in adjacent rooms 99= DK
582 snore_fr 15c. Over the past month, how often have you been snoring? 1= NOT AT ALL 2= LESS THAN ONCE A WEEK 3= ONCE OR TWICE A WEEK 4= THREE OR MORE TIMES A WEEK 5= NEARLY EVERY DAY 99= DK
583 breathpa 16. During the past month, how often have others noticed that you quit breathing or have long pauses between breaths during sleep? 1= NOT AT ALL 2= LESS THAN ONCE A WEEK 3= ONCE OR TWICE A WEEK 4= THREE OR MORE TIMES A WEEK 5= NEARLY EVERY DAY 99= DK
584 sleepapn 17. Are you currently being treated for sleep apnea (e.g. CPAP)? 0= No 1= Yes
585 actdream Mayo Sleep Questionnaire – Please mark “Yes” if the described event has occurred at least 3 times. 18 . Have you ever been told that you appear to 'act out your dreams' while sleeping? (Punched or flailed arms in the air, shouted or screamed) 0= No 1= Yes
586 actdrea2 18a. How many months or years has this been going on? [Years] 0 .. 99
587 actdrea3 18a. How many months or years has this been going on? [Months] 18a-1. [Months] 0 .. 11
588 actdrea4 18b. Have you ever been injured from these behaviors (bruises, cuts, broken bones)? 0= No 1= Yes
589 actdrea5 18c. Has your bed-partner ever been injured from these behaviors (bruises, blows, pulled hair)? 0= No 1= Yes
590 dreamatt 18d. Have you ever had dreams about being attacked, or that involved defending yourself? 0= No 1= Yes
591 movdream 18e. Have you ever been told that the movements you made matched the details of your dream? 0= No 1= Yes
592 sleepwal 19. Have you ever been told that you walked around the bedroom or house while asleep? (please mark Yes if the described event has occurred at least 3 times) 0= No 1= Yes
593 sleepwa2 19a. If yes, how often does this occur? 0= Almost never 2= Less than once a week 3= Once or twice a week 4= Three or more times a week 5= Nearly every day
594 legtwitc 20. During the past month, how often have your legs repeatedly jerked or twitched during sleep (not just while falling asleep)? 1= NOT AT ALL 2= LESS THAN ONCE A WEEK 3= ONCE OR TWICE A WEEK 4= THREE OR MORE TIMES A WEEK 5= NEARLY EVERY DAY 99= DK
595 legdisru 21. During the past month, how often have you had a restless, nervous, tingly, or creepy-crawly feeling in your legs that disrupts your ability to fall or stay asleep? 1= Not at all 2= Less than once a week 3= Once or twice a week 4= Three or more times a week 5= Nearly every day
596 legdisr2 21a. Do these leg sensations decrease when you walk around? 0= No 1= Yes
597 legdisr3 21b. When do these sensations seem to be the worst? 1= Before 6pm 2= After 6pm
598 cov1 Revised COVID FORM 2022 This form serves as an update to the original COVID-19 Survey released in summer 2020, and reflects on several important updates since that time, including vaccinations and evolving understanding of the long-term impacts of COVID-19 particularly on cognitive function. We are asking these questions because COVID-19 has presented multiple challenges for us all, and we would like to learn about your experience. 1. Have you been diagnosed with COVID-19 (you tested positive or were presumed to have COVID-19 by a healthcare provider)? 0= No 1= Yes, based on a positive test for acute infection 2= Yes, presumed COVID-19 diagnosis by healthcare provider but not tested 8= Decline to answer 9= Unsure/unknown
599 cov1a Revised COVID FORM 2022 1a. How many times have you been diagnosed with COVID-19 (distinct episodes of illness)? 1= Once 2= Twice 3= Three or more times 9= Unsure/unknown
600 cov1b Revised COVID FORM 2022 1b. When did your first COVID-19 infection begin (month/year)? [ 88/8888 = Decline to answer ] String[7]
601 cov1c Revised COVID FORM 2022 1c. What was the duration of your first COVID-infection? 1= <1 week 2= 1-2 weeks 3= 2-4 weeks 4= >4 weeks 5= Not yet recovered (symptoms persist to the present)
602 cov1d Revised COVID FORM 2022 1d. During any of your COVID-19 infections, did you lose the ability to smell or taste, experience lower ability to determine smells or tastes, or experience episodes of unprovoked, unfamiliar, or strange smells or tastes? 0= No 1= Yes 8= Decline to answer 9= Unsure/unknown
603 cov1e Revised COVID FORM 2022 1e. During any of your COVID-19 infections, did you experience new problems with thinking, remembering, or concentration (e.g., brain fog)? 0= No 1= Yes 8= Decline to answer 9= Unsure/unknown
604 cov1f Revised COVID FORM 2022 1f. Did you ever seek medical care for COVID-19? 0= No 1= Yes 8= Decline to answer 9= Unsure/unknown
605 cov1g Revised COVID FORM 2022 1g. What was the highest level of care received? 1= Physician or urgent care visit, including virtual care visit 2= Emergency department 3= Hospitalized but not the intensive care unit 4= Hospitalized, including a stay in the ICU and/or ventilator support (breathing tube in your throat) 8= Decline to answer 9= Unsure/unknown
606 cov1h Revised COVID FORM 2022 1h. To what degree have you recovered from your COVID-19 symptoms (scale 1 to 5)? 1= No improvement 2= Slightly improved 3= Somewhat improved 4= Mostly improved 5= Totally recovered or never had symptoms 8= Decline to answer 9= Unsure/unknown
607 cov2 Revised COVID FORM 2022 2. Have you received at least one vaccination against COVID-19? 0= No 1= Yes 8= Decline to answer 9= Unsure/unknown
608 ivisit visit
609 cuff BLOODPRESSURE Now I would like to take some blood pressure readings. 3. IS CUFF SIZE AVAILABLE? [IF CUFF NOT AVAILABLE, AT END OF INTERVIEW SET UP TIME TO RETURN FOR BLOOD PRESSURE MEASUREMENT] 1= Yes 2= No
610 bp11 6. FIRST SITTING BLOOD PRESSURE READING [INTERVIEWER: The subject should be seated for five minutes prior to obtaining the seated blood pressure readings. ENTER SYSTOLIC/DIASTOLIC] String[7]
611 bp2 7. SECOND SITTING BLOOD PRESSURE READING [INTERVIEWER: ENTER SYSTOLIC/DIASTOLIC] String[7]
612 bp31 8. STANDING BLOOD PRESSURE READING [INTERVIEWER: ASK THE SUBJECT TO STAND. WAIT 60 SECONDS THEN REPEAT BLOOD PRESSURE READING. ENTER SYSTOLIC/DIASTOLIC] String[7]
613 howwell 1. INTERVIEWER OBSERVATIONS How well do you think the participant understood the questions? 1= Quite well 2= Fairly well 3= Somewhat 4= Very Little 5= Not at all
614 hearimp 2. Does the participant have a SUBSTANTIAL hearing impairment? 1= Yes 2= No
615 visimp 3. Does the participant have a SUBSTANTIAL visual impariment? 1= Yes, completely blind 2= Yes, very poor 3= Yes, poor 4= No, not substantial
616 phyeffrt 4. How great an effort do you think the participant put into the examination? 1= A great deal 2= A considerable amount 3= A moderate amount 4= A little bit 5= Hardly any
617 comm Comments. String[120]
618 autotm1 [COMPUTER CLOCK TIME] String[8]
619 report1 CLIN EVAL SUMMARY: SUBJECT ^intro.projid; Date: ^intro.dateint SUMM PG 1/10 AREA IMPAIRMENT LEVEL RANGE SCORE (Missing~) Bradykinesia ^VBrady 8-48 ^brady.ScBrady (^brady.mbrady of 8) Postural Reflex ^Vreflex 6-32 ^sensgait.Screflex^x1 (^sensgait.mreflex of 6) Rigidity ^Vrigid 5-25 ^hyper.ScRigid^x2 (^hyper.mrigid of 5) [~NOTE: If any data are missing, this will affect the computation of the impairment level.] >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
620 report2 CLIN EVAL SUMMARY: SUBJECT ^intro.projid; Date: ^intro.dateint SUMM PG 2/10 AREA IMPAIRMENT LEVEL RANGE SCORE (Missing~) Postural tremor ^Vptrem 0-8 ^tremor.Scptrem (^tremor.mposttrm of 2) Resting tremor ^Vrtrem 5-30 ^tremor.Scrtrem^x3 (^tremor.mresttrm of 5) Parkinsonism: ^Parkvar ^ps1^ps2^ps4^ps7^ps10 >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
621 report3 HISTORY FROM CLIN EVAL: SUBJECT ^intro.projid; Date: ^intro.dateint SUMM PG 3/10 Stroke: ^strovar ^s1^s2^s3^s4^s6^s9^s12^s15^cervasc.sympspe0^s17 Current Drugs: ^drugvar^drugs.RXs.medicine[1].name00 ^drugs.RXs.medicine[2].name00 ^drugs.RXs.medicine[3].name00 ^drugs.RXs.medicine[4].name00 ^drugs.RXs.medicine[5].name00 ^drugs.RXs.medicine[6].name00 ^drugs.RXs.medicine[7].name00 ^drugs.RXs. medicine[8].name00 ^drugs.RXs.medicine[9].name00 ^drugs.RXs.medicine[10].name00 ^drugs.RXs.medicine[11].name00 ^drugs.RXs.medicine[12].name00 ^drugs.RXs.medicine[13].name00 ^drugs.RXs.medicine[14].name00 ^drugs.RXs.medicine[15].name00 ^drugs.RXs. medicine[16].name00 ^drugs.RXs.medicine[17].name00 ^drugs.RXs.medicine[18].name00 ^drugs.RXs.medicine[19].name00 ^drugs.RXs.medicine[20].name00 PRESS ENTER FOR NEXT SUMMARY SCREEN
622 report3a HISTORY FROM CLIN EVAL: SUBJECT ^intro.projid; Date: ^intro.dateint SUMM PG 3a/10 Stroke with hospitalization: ^strovar2 ^s201^s202^s203^s204^s205^s206^s208^s209^s211^s212^s214^s215 ^cervasc.sympspe1^s217 >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
623 report3b HISTORY FROM CLIN EVAL: SUBJECT ^intro.projid; Date: ^intro.dateint SUMM PG 3b/10 Stroke with brain scan: ^strovar3 ^s301^s302^s303^s304^s305^s306^s308^s309^s311^s312^s314^s315 ^cervasc.sympspe2^s317 >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
624 report4 NEURO EXAM - FOCAL SIGNS: SUBJECT ^intro.projid Date: ^intro.dateint SUMM PG 4/10 CRANIAL NERVES ^normal^a5^a6^a7^a8 Brain scan: ^scanvar ^reason ^whyscan^cervasc.reason PRESS ENTER FOR NEXT SUMMARY SCREEN
625 report5 NEURO EXAM - FOCAL SIGNS: SUBJECT ^intro.projid Date: ^intro.dateint SUMM PG 5/10 Seventh Nerve: ^normal ^c1^d1^c2^d2^c3^d3^c4^d4 >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
626 report6 NEURO EXAM - FOCAL SIGNS: SUBJECT ^intro.projid Date: ^intro.dateint SUMM PG 6/10 FOCAL SIGNS: ARM STRENGTH SYMMETRY ^normal2^e1^f1^e2^f2^e3^f3^e4^e5^e6^g1^g2^g3 >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
627 report7 NEURO EXAM - FOCAL SIGNS: SUBJECT ^intro.projid Date: ^intro.dateint SUMM PG 7/10 FOCAL SIGNS: LEG STRENGTH SYMMETRY ^normal2^e2^g4^h4^g5^h5^g6^h6^i4^i5^i6^j4^j5^j6^a5 >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
628 report8 NEURO EXAM - FOCAL SIGNS: SUBJECT ^intro.projid Date: ^intro.dateint SUMM PG 8/10 DEEP TENDON REFLEXES: ^normal2 ^g4^h4^g5^h5^g6^h6^g7^h7^g8^h8 BABINSKI SIGN: ^normal3 ^k1^k2 >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
629 report9 NEURO EXAM-FOCAL SIGNS: SUBJECT ^intro.projid Date: ^intro.dateint SUMM PG 9/10 SENSORY FUNCTION Pin Sensation: ^normal1 ^a1^b1^a2^b2 Vibratory Sensation: ^normal3^a6 ^a7 >>>>> PRESS ENTER FOR NEXT SUMMARY SCREEN <<<<<
630 report10 NEURO EXAM-FOCAL SIGNS: SUBJECT ^intro.projid Date: ^intro.dateint SUMM PG 10/10 CEREBELLAR FUNCTION FINGER-TO-FINGER: ^normal1 ^a1^a2 GAIT: ^normal3^a5 ^a6^a7 >>>>> END OF SUMMARY SECTION <<<<
631 formcode Please enter status code. 11 = COMPLETE 13 = COMPLETE, portion with proxy 12 = INCOMPLETE, refused 14 = INCOMPLETE, too impaired 21 = INCOMPLETE interim, complete later 73 = NOT TESTED, out of town 31 = NOT TESTED, moved 33 = NOT TESTED, refused 75 = NOT TESTED, hospitalized 76 = NOT TESTED, other 42 = DECEASED 43 = WITHDRAWN 44 = WITHDRAWN, Autopsy OK 11 .. 76
632 formpart Was participant reluctant, and/or does participant have special needs? 1= Yes 2= No
633 formcomm Please explain reluctance or any other factors which may have affected this data. [Press enter if no comment needed.] String[120]
634 statid Please enter you staff id. 100 .. 997
635 formch Has the form been modified? 1= Yes 2= No
636 revidate Enter the date that the form was modified. Date type
637 revintd Enter your staff id number. 100 .. 997

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