Medical History - National Institutes of Health



*Date of Pulmonary Function Testing: (mm/dd/yyyy)Attempted, but failed. Indicate reason*: FORMCHECKBOX Fatigue FORMCHECKBOX URI/LRI/severe coughing FORMCHECKBOX Behavioral issues FORMCHECKBOX Equipment failure FORMCHECKBOX Unable to follow directions FORMCHECKBOX Low oral motor tone/unable to hold mouthpiece FORMCHECKBOX Unable to get subject into supine position due to scoliosis, contractures, cannot move to bed (for supine only) FORMCHECKBOX Other, specify:What type of pulmonary testing is being performed? (Check all that apply. Record results in appropriate tables below): FORMCHECKBOX Slow Vital Capacity (SVC) FORMCHECKBOX Maximum Inspiratory Pressure (MIP) FORMCHECKBOX Helium Lung Volumes FORMCHECKBOX MVV FORMCHECKBOX Maximum Expiratory Pressure FORMCHECKBOX Unassisted Peak Cough Flow (PCF) FORMCHECKBOX Forced Vital Capacity (FVC) FORMCHECKBOX Inspiratory Capacity (IC) FORMCHECKBOX Other, specify:Note: Position should remain consistent for all trials.Position for the assessment: FORMCHECKBOX Sitting FORMCHECKBOX Supine (FVC only) FORMCHECKBOX Both (sitting and supine)If assessment performed sitting, what was the subject’s seated position? FORMCHECKBOX Semi-erect FORMCHECKBOX Erect FORMCHECKBOX Leaning forward FORMCHECKBOX N/A-assessment done supineWhat type of mouthpiece was used?: FORMCHECKBOX Scuba FORMCHECKBOX Cardboard FORMCHECKBOX MaskType of Pulmonary Function Testing Equipment used:Table 1 Pulmonary Function Testing EquipmentManufacturer:Model:Software Program:Data to be entered by siteData to be entered by siteData to be entered by siteAdditional Pediatric-specific ElementsThese elements are recommended for pediatric studiesUlna length: [pre-populated field] cmUlna length measured with: FORMCHECKBOX Harpenden Anthropomenter FORMCHECKBOX Segmomenter, type:Was patient taking brochodulator at time of testing? FORMCHECKBOX Yes FORMCHECKBOX NoTable 2 Index of Lung FunctionIndex of Lung FunctionTrial 1Trial 2Trial 3Complete Exhalation: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoFVC*(liters)*(liters) FORMCHECKBOX Check if Best Trial*(liters) FORMCHECKBOX Check if Best Trial*(liters) FORMCHECKBOX Check if Best TrialFEV1 (liters)Data to be entered by siteData to be entered by siteData to be entered by siteFEV1/FVC(ratio/ no units)Data to be entered by siteData to be entered by siteData to be entered by siteFEV0.5 (liters)Data to be entered by siteData to be entered by siteData to be entered by siteFEV0.5/FVC (ratio/ no units)Data to be entered by siteData to be entered by siteData to be entered by siteFEF25-75 (liters/ second)Data to be entered by siteData to be entered by siteData to be entered by siteFEFmax(liters/ second)Data to be entered by siteData to be entered by siteData to be entered by sitePCF (liters/ second)Data to be entered by siteData to be entered by siteData to be entered by siteSNIP (cmH20)Data to be entered by siteData to be entered by siteData to be entered by siteTLC (liters)Data to be entered by siteData to be entered by siteData to be entered by siteSVC (liters)Data to be entered by siteData to be entered by siteData to be entered by siteIC (liters)Data to be entered by siteData to be entered by siteData to be entered by siteFRC (liters)Data to be entered by siteData to be entered by siteData to be entered by siteRV (liters)Data to be entered by siteData to be entered by siteData to be entered by siteFRC/TLC (ratio/ no unit)Data to be entered by siteData to be entered by siteData to be entered by siteRV/TLC(ratio/ no unit)Data to be entered by siteData to be entered by siteData to be entered by siteMEP (cm of water)Data to be entered by siteData to be entered by siteData to be entered by siteMIP (cm of water)Data to be entered by siteData to be entered by siteData to be entered by siteAdditional questions for MIP/MEPWas there a difference of greater than 3 cm of H2O between trial efforts? FORMCHECKBOX Yes FORMCHECKBOX NoAdditional questions for Forced Vital Capacity (FVC):Was there a cough during the first second of exhalation? FORMCHECKBOX Yes FORMCHECKBOX NoWas there a leak during exhalation? FORMCHECKBOX Yes FORMCHECKBOX NoAre the 2 largest values for FVC within 10% of each other? FORMCHECKBOX Yes FORMCHECKBOX NoWas there early termination with steep cut off? FORMCHECKBOX Yes FORMCHECKBOX NoWas there a clearly defined peak flow? FORMCHECKBOX Yes FORMCHECKBOX NoGENERAL INSTRUCTIONSThis CRF is used to capture data on Pulmonary Function Testing the participant/ subject is undergoing during the course of the study.SPECIFIC INSTRUCTIONSPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Position for the Assessment– Please note that “Supine” is for FVC only.Ulna length–If the Date performed on this form is the same as the Date performed on the Vital Signs form, then this field will be pre-populated from the value recorded on the Vital Signs form. For those whose standing height or recumbent height is unable to be measured, then ulna length should be recorded. Arm span length can be used (instead of ulna length), however, arm span length is not a surrogate for height. ................
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