Form Structure: CAGE Questionnaire
This form structure is an organized set of data definitions for a copyrighted form
Resource:
FITBIR
Title:
CAGE Questionnaire
Short Name:
CAGE
Description:
CAGE Substance Abuse Screening Tool Questionnaire
Disease:
Traumatic Brain Injury
Organization:
CTDB - NICHD
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-02-11
Version:
1.0
Date Created:
2015-01-09
Owner:
Number of Data Elements:
14
eForms:
N
Logically grouped data elements with defined frequency at which they repeat.
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | GUID | Global Unique ID which uniquely identifies a subject | GUID | Required | CDE |
| 2 | Subject identifier number | An identification number assigned to the participant/subject within a given protocol or a study. | SubjectIDNum | Optional | CDE |
| 3 | Age in years | Value for participant's subject age recorded in years. | AgeYrs | Recommended | CDE |
| 4 | Visit date | Actual interview or visit date | VisitDate | Recommended | CDE |
| 5 | Site name | The name of the site for the study | SiteName | Recommended | CDE |
| 6 | Days since baseline | The number of days since baseline | DaysSinceBaseline | Optional | CDE |
| 7 | Case control indicator | Indicator of whether subject is in the case or control arm of the study. | CaseContrlInd | Optional | CDE |
| 8 | General notes text | General notes | GeneralNotesTxt | Optional | CDE |
Additional Element Groups
Listed below are your additional element groups.
CAGE Questions (Repeat Infinitely)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | CAGE Substance Abuse Screening Tool Questionnaire - Need decrease drinking indicator | The indicator related to feelings toward the need to cut down on the amount of alcohol consumed, as part of the CAGE Substance Abuse Screening Tool Questionnaire. | CAGECutDownDrinkingInd | Recommended | CDE |
| 2 | CAGE Substance Abuse Screening Tool Questionnaire - Drinking associated criticism annoyance indicator | The indicator related to feeling annoyed due to others criticizing their alcohol consumption, as part of the CAGE Substance Abuse Screening Tool Questionnaire. | CAGEAnnoyedCriticizeDrinkInd | Recommended | CDE |
| 3 | CAGE Substance Abuse Screening Tool Questionnaire - Drinking associated guilt indicator | The indicator related to feeling bad or guilt when drinking, as part of the CAGE Substance Abuse Screening Tool Questionnaire. | CAGEGuiltyDrinkingInd | Recommended | CDE |
| 4 | CAGE Substance Abuse Screening Tool Questionnaire - Morning drinking indicator | The indicator related to having a drink in the morning to steady nerves or get rid of a hangover, as part of the CAGE Substance Abuse Screening Tool Questionnaire. | CAGEDrinkMorningInd | Recommended | CDE |
| 5 | CAGE Substance Abuse Screening Tool Questionnaire - Total score | Total score of all questions in the CAGE Substance Abuse Screening Tool Questionnaire. | CAGETotalScore | Recommended | CDE |
| 6 | CAGE Substance Abuse Screening Tool Questionnaire - Clinically significant indicator | The indicator of whether the total score for the CAGE Substance Abuse Screening Tool Questionnaire is clinically significant. | CAGEClinicallySignificantInd | Recommended | CDE |
Keywords
