Self-Reported Symptoms



Headache Self-ReportDo you have pressure at the base of your head? REF Core \h 1 FORMCHECKBOX Yes FORMCHECKBOX NoDoes your pain radiate behind your eyes? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDoes your pain radiate to your neck or shoulders? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoIs the pain worsened by coughing, crying, laughing, sneezing, orgasms, bowel movements? REF Core \h 1 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have general neck pain/stiffness? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoOcular Self-ReportDo you have pain or pressure behind your eyes? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoAre you sensitive to light? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have blurred vision? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have double vision? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoAre you missing a portion of your visual field when looking straight ahead (Field Cuts) with either or both eyes? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoOtoneurological Self-ReportDo you have pressure in your ears? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have dizziness with position changes? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have feelings of unsteadiness when standing? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have feelings of unsteadiness when walking? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have high-pitched ringing in your ears? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have tremors? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have decreased hearing? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have very sensitive hearing? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have vertigo (feelings that you or the room are spinning)? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoCranial Nerve-Brainstem Self-ReportDo you have difficulty swallowing? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have throat tightness? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have difficulty speaking? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoIs your voice changing, becoming hoarse? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have sleep apnea? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you snore? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever “passed out”? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have palpitations? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you ever have shortness of breath? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have frequent nausea? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoExtracranial Self-ReportDo you suffer from prickling, tingling or numbness of your extremities? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have increased sensitivity to pain or touch? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have diminished sensitivity to pain? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have partial or complete loss of sensation in your extremities? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have an abnormal burning pain in your extremities? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have pain or decreased sensation over a specific portion of your extremities? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have any noticeable skin changes? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoIf you close your eyes or are in the dark, do you have difficulty with your balance? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have weakness of your extremities? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have loss of muscle tone? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have difficulty picking up small objects with your fingers? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have stiffness of your arms or legs? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoUrological Self-ReportDo you have difficulty controlling the urge to urinate? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have urinary incontinence (Have you accidentally leaked urine)? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have difficulty initiating your urine stream? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you urinate more than 10 times per day? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you go two or more times in succession before completely emptying your bladder? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you awaken from sleep two or more times to urinate? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have a history of recurring urinary bladder or kidney infections? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been diagnosed with interstitial cystitis? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been diagnosed with a urethral stricture or prostate problems? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoGastrointestinal Self-ReportDo you have constipation? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you suffer from diarrhea? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you had occasional incontinence for stools (fecal soiling)? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been diagnosed with irritable bowel syndrome (IBS)? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been diagnosed with celiac disease or gluten sensitivity? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been diagnosed with Crohn's disease or colitis? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoSexual Self-ReportDo you have a decreased interest in sex (reduced libido)? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have difficulty maintaining arousal? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have difficulty reaching orgasm? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you lost the ability to reach an orgasm, sustain an erection, or ejaculate properly? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you experienced a decrease or loss of sensation in your pelvic (or genital) area? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoCognitive Self-ReportDo you suffer from short-term memory loss? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you suffer from long-term memory loss? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have difficulty making decisions? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have word finding problems? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you suffer from depression? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you suffer from irritability? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoSystemic Self-ReportDo you suffer from chronic fatigue? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have nipple discharge? REF Exploratory \h 4 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have joint hypermobility? REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDo you have wound healing problems? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you been diagnosed with thyroid problems? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you been diagnosed with any pituitary problems? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoHave you experienced any bleeding or blood clotting disorders? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoWomen: Do you have irregular periods? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoWomen: Do you have unexpected milk production at the breast? REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoPrecipitating CausesNeurologic testingMRI Brain REF Core \h 1 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Cine MRI (CSF flow study) REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:MRI Cervical Spine REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:MRI Thoracic Spine REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:MRI Lumbar Spine REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:CT Head REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:CT Cervical Spine REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:CT Thoracic Spine REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/imageCT Lumbar Spine REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:CT Myelogram REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:X-ray Skull REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:X-ray Shunt Series REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:X-ray Cervical Spine REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:X-ray Thoracic Spine REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:X-ray Lumbar Spine REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:PET Scan: Brain REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Lumbar Puncture REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Stellate Ganglion Block REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Other: REF Exploratory \h 4Date of test/image:Misc. TestingVestibular Function Testing REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Tilt Table REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Holter Monitor REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Barium Swallow REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Sleep Apnea Monitoring REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Sleep EEG Monitoring REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Pulmonary Function Tests REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Other: REF Supplemental \h 3Date of test/image:LaboratoryPituitary Hormone Profile REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Lyme Titer REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Rheumatology Panel REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Other: REF Supplemental \h 3Date of test/image:ConsultationsPain Management REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Neurology REF Core \h 1 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Neuropsychology REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Cardiology REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Rheumatology REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Allergist REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Nutritional Assessment REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Coagulation/Hematology REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:ENT/Otolaryngology REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Orthopedics REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Endocrinology REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Genetics REF SupplementalHighlyRecommended \h 2 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Urology REF Supplemental \h 3 FORMCHECKBOX Yes FORMCHECKBOX NoDate of test/image:Other: REF Exploratory \h 4Date of test/image:InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Specific Module Instructions:Headache Symptoms:There are Core and Supplemental–Highly Recommended data elements in this module.Ocular Symptoms:There are no Core or Supplemental–Highly Recommended data elements in this module. All data elements are Supplemental and could be collected on clinical studies only if research team considers them appropriate for their study.Otoneurological Symptoms:There is one Supplemental–Highly Recommended data element in this module. All other data elements are Supplemental and could be collected on clinical studies only if research team considers them appropriate for their study.Cranial Nerve-Brainstem Symptoms: There are Supplemental–Highly Recommended data elements in this module.Extracranial Symptoms: There are Supplemental–Highly Recommended data elements in this module.Urological Symptoms: There are no Core or Supplemental–Highly Recommended data elements. All data elements are Supplemental and could be collected on clinical studies only if research team considers them appropriate for their study.GI Symptoms: There are no Core or Supplemental–Highly Recommended data elements in this module. All data elements are Supplemental and could be collected on clinical studies only if research team considers them appropriate for their study.Sexual Symptoms: There are no Core or Supplemental–Highly Recommended data elements in this module. All data elements are Supplemental and could be collected on clinical studies only if research team considers them appropriate for their study.Cognitive Symptoms: There are no Core or Supplemental–Highly Recommended data elements in this module. All data elements are Supplemental and could be collected on clinical studies only if research team considers them appropriate for their study.Systemic Symptoms: There is one Supplemental–Highly Recommended and one Exploratory data element in this module.Precipitating Causes: There are Core, Supplemental–Highly Recommended, and Exploratory data elements in this module. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download