A1 |
BIRTHMO |
Subject's month of birth |
A1 |
BIRTHYR |
Subject's year of birth |
A1 |
SEX |
Subject's sex |
A1 |
HISPANIC |
Does the subject report being of Hispanic/Latino ethnicity (i.e., having origins from a mainly Spanish-speaking Latin American country), regardless of race? |
A1 |
HISPOR |
If yes, what are the subject's reported origins? |
A1 |
HISPORX |
Other (specify): |
A1 |
RACE |
What does the subject report as his or her race? |
A1 |
RACEX |
Other (specify): |
A1 |
RACESEC |
What additional race does subject report? |
A1 |
RACESECX |
Other (specify): |
A1 |
RACETER |
What additional race, beyond those reported in Questions 9 and 10, does subject report? |
A1 |
RACETERX |
Other (specify): |
A1 |
EDUC |
|
A1 |
MARISTAT |
Subject's current marital status: |
A1 |
RESIDENC |
What is the subject's primary type of residence? |
A1 |
ZIP |
ZIP Code (first three digits) of subject's primary residence: |
A5 |
TOBAC30 |
Has subject smoked within the last 30 days? |
A5 |
TOBAC100 |
Has subject smoked more than 100 cigarettes in his/her life? |
A5 |
SMOKYRS |
Total years smoked |
A5 |
PACKSPER |
Average number of packs smoked per day |
A5 |
QUITSMOK |
If the subject quit smoking, specify age at which he/she last smoked (i.e., quit) |
A5 |
CVHATT |
Heart attack/cardiac arrest |
A5 |
HATTMULT |
More than one heart attack? |
A5 |
HATTYEAR |
Year of most recent heart attack |
A5 |
PD |
Parkinson's disease (PD) |
A5 |
PDYR |
Year of PD diagnosis |
A5 |
TBI |
Traumatic brain injury (TBI) |
A5 |
TBIBRIEF |
TBI with brief loss of consciousness (< 5 minutes) |
A5 |
TBIEXTEN |
TBI with extended loss of consciousness (5 minutes or longer) |
A5 |
TBIWOLOS |
TBI without loss of consciousness (as might result from military detonations or sports injuries)? |
A5 |
TBIYEAR |
Year of most recent TBI |
A5 |
DIABETES |
Diabetes |
A5 |
HYPERTEN |
Hypertension |
A5 |
THYROID |
Thyroid disease |
A5 |
INCONTF |
Incontinence — Bowel |
B1 |
HEIGHT |
Subject height (inches): |
B1 |
WEIGHT |
Subject weight (lbs) |
B1 |
BPSYS |
Subject blood pressure (sitting) |
B1 |
BPDIAS |
Subject blood pressure (sitting), diastolic |
B1 |
VISCORR |
Does the subject usually wear corrective lenses? |
B1 |
HEARAID |
Does the subject usually wear a hearing aid(s)? |
B1 |
HEARWAID |
If yes, is the subject's hearing functionally normal with a hearing aid(s)? |
B8 |
PARKSIGN |
Parkinsonian signs |
B8 |
RESTTRL |
Resting tremor — left arm |
B8 |
RESTTRR |
Resting tremor — right arm |
B8 |
BRADY |
Bradykinesia |
B8 |
PARKGAIT |
Parkinsonian gait disorder |
B8 |
CVDSIGNS |
Neurological sign considered by examiner to be most likely consistent with cerebrovascular disease |
B9 |
DECSUB |
Does the subject report a decline in memory (relative to previously attained abilities)? |
B9 |
DECCLCOG |
Based on the clinician's judgment, is the subject currently experiencing meaningful impairment in cognition? |
B9 |
COGMEM |
Indicate whether the subject currently is meaningfully impaired, relative to previously attained abilities, in memory |
C1 |
MMSECOMP |
Was any part of the MMSE completed? |
C1 |
MMSEREAS |
Reason code for not completing MMSE |
C1 |
MMSELOC |
Administration of the MMSE was |
C1 |
MMSELAN |
Language of MMSE administration |
C1 |
MMSELANX |
Language of MMSE administration — Other (specify): |
C1 |
MMSEVIS |
Subject was unable to complete one or more sections due to visual impairment |
C1 |
MMSEHEAR |
Subject was unable to complete one or more sections due to hearing impairment |
C1 |
MMSEORDA |
Orientation subscale score — Time |
C1 |
MMSEORLO |
Orientation subscale score — Place |
C1 |
PENTAGON |
Intersecting pentagon subscale score |
C1 |
MMSE |
Total MMSE score (using D-L-R-O-W) |
C1 |
NPSYCLOC |
The remainder of the battery was administered |
C1 |
NPSYLAN |
Language of test administration |
C1 |
NPSYLANX |
Language of test administration — Other (specify) |
C1 |
LOGIMEM |
Total number of story units recalled from this current test administration |
C1 |
DIGIF |
Total number of trials correct before two consecutive errors at the same digit length |
C1 |
DIGIB |
Total number of trials correct before two consecutive errors at the same digit length |
C1 |
ANIMALS |
Animals — Total number of animals named in 60 seconds |
C1 |
VEG |
Vegetables — Total number of vegetables named in 60 seconds |
C1 |
MEMUNITS |
Logical Memory IIA — Delayed — Total number of story units recalled |
C1 |
MEMTIME |
Logical Memory IIA — Delayed — Time elapsed since Logical Memory IA — Immediate |
D1 |
DXMETHOD |
Diagnosis method — Responses in this form are based on diagnosis by: |
D1 |
NORMCOG |
Does the subject have normal cognition (global CDR=0 and/or neuropsychological testing within normal range) and normal behavior (i.e., the subject does not exhibit behavior sufficient to diagnose MCI or dementia due to FTLD or LBD)? |
D1 |
DEMENTED |
Does the subject meet criteria for dementia? |
D1 |
AMNDEM |
Amnestic multidomain dementia syndrome |
D1 |
PCA |
Posterior cortical atrophy syndrome (or primary visual presentation) |
D1 |
NAMNDEM |
Non-amnestic multidomain dementia, not PCA, PPA, bvFTD, or DLB syndrome |
D1 |
ALZDIS |
Alzheimer's disease |
D1 |
LBDIS |
Lewy body disease |
D1 |
PARK |
Parkinson's disease |
D1 |
MSA |
Multiple system atrophy |
D1 |
PSP |
Progressive supranuclear palsy (PSP) |
D1 |
CVD |
Vascular brain injury (based on clinical and imaging evidence) |
D1 |
CVDIF |
Vascular brain injury, primary or contributing |
D1 |
HUNT |
Huntington's disease |
D1 |
PRION |
Prion disease (CJD, other) |
D1 |
BRNINJ |
Traumatic brain injury |
D1 |
BRNINJIF |
Traumatic brain injury, primary or contributing |
D1 |
HYCEPH |
Normal-pressure hydrocephalus |
D1 |
HYCEPHIF |
Normal-pressure hydrocephalus, primary or contributing |
D1 |
HIV |
Human immunodeficiency virus (HIV) |
D1 |
HIVIF |
Human immunodeficiency virus (HIV), primary or contributing |
D1 |
OTHCOG |
Cognitive impairment due to other neurologic, genetic, or infectious conditions not listed above |
D1 |
OTHCOGIF |
Cognitive impairment due to other neurologic, genetic, or infectious conditions not listed above, primary or contributing |
D1 |
OTHCOGX |
Cognitive impairment due to other neurologic, genetic, or infectious conditions not listed above — if present, specify: |
D1 |
DEP |
Active depression |
D1 |
DEPIF |
Active depression, primary or contributing |
D1 |
ALCDEM |
Cognitive impairment due to alcohol abuse |
D1 |
ALCABUSE |
Current alcohol abuse: |
D2 |
HYPERT |
Hypertension |
D2 |
THYDIS |
Thyroid disease |
D2 |
BOWLINC |
Incontinence — bowel |