Form Structure: NIH Toolbox Sensation Domain Pain Intensity Survey
This form structure is an organized set of data definitions for a copyrighted form
Title:
NIH Toolbox Sensation Domain Pain Intensity Survey
Short Name:
NIHTBPainIntensitySurvey
Description:
Sensation Domain: The NIH Toolbox Pain Intensity Survey consists of a single item measuring immediate (i.e., acute) pain in adults. It asks a participant to rate his/her level of pain experienced over the last seven days. It takes less than one minute to administer and is recommended for ages 18-85. This test is part of the NIH Toolbox Sensory Domain Pain Measure. Copyright 2012 Northwestern University and the National Institutes of Health. http://www.nihtoolbox.org/Pages/NIH-Toolbox-Terms-and-Conditions.aspx
Disease:
General (For all diseases)
Traumatic Brain Injury
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2016-09-29
Version:
1.0
Date Created:
2016-05-19
Owner:
Number of Data Elements:
26
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 | Vital status | Status of participant/subject as alive or dead | VitStatus | Optional | CDE |
| 5 | Visit date | Actual interview or visit date | VisitDate | Recommended | CDE |
| 6 | Site name | The name of the site for the study | SiteName | Recommended | CDE |
| 7 | Days since baseline | The number of days since baseline | DaysSinceBaseline | Optional | CDE |
| 8 | Case control indicator | Indicator of whether subject is in the case or control arm of the study. | CaseContrlInd | Optional | CDE |
| 9 | General notes text | General notes | GeneralNotesTxt | Optional | CDE |
Additional Element Groups
Listed below are your additional element groups.
Form Administration (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Context type | The context to which the questions were answered | ContextType | Recommended | CDE |
| 2 | Context type other text | The free-text related to ContextType specifying other text | ContextTypeOTH | Recommended | CDE |
| 3 | Data source | Source of the data provided on the case report form | DataSource | Recommended | CDE |
| 4 | Data source other text | The free-text field related to Data source specifying other text. Source of the data provided on the case report form | DataSourceOTH | Recommended | CDE |
NIH Toolbox Administration (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 |
NIH Toolbox - Test domain battery type
(Retired) |
Type of domain battery for the NIH Toolbox test being administered, as a part of the NIH Toolbox | NIHTBTestDomainBatteryTyp | Recommended | CDE |
| 2 | NIH Toolbox - Test domain battery type other | The free-text related to NIHTBTestDomainBatteryTyp specifying other text, as part of the NIH Toolbox | NIHTBTestDomainBatteryTypOTH | Recommended | CDE |
| 3 | NIH Toolbox - Test name type | Type of NIH Toolbox test being administered, as part of the NIH Toolbox | NIHTBAdminTestNameTyp | Recommended | CDE |
| 4 | NIH Toolbox - Test name type other | The free-text related to NIHTBAdminTestNameTyp specifying other text, as part of the NIH Toolbox | NIHTBAdminTestNameTypOTH | Recommended | CDE |
| 5 | NIH Toolbox - Test administration language type | Type of language for test being administrated, as part of the NIH Toolbox | NIHTBTestAdminLanguageTyp | Recommended | CDE |
| 6 | NIH Toolbox - Test administration language type other | Free-text related to NIHTBTestAdminLanguageTyp specifying other text, as part of the NIH Toolbox | NIHTBTestAdminLanguageTypOTH | Recommended | CDE |
| 7 | NIH Toolbox - Form administered type | Type of NIH Toolbox form being administered, as part of the NIH Toolbox | NIHTBFormAdminTyp | Recommended | CDE |
| 8 | NIH Toolbox - Test administration flag type | Type of flag for the NIH Toolbox test being administered, as part of the NIH Toolbox | NIHTBAdminTestFlagTyp | Recommended | CDE |
| 9 | NIH Toolbox - Test administration flag indicator | Indicator of a flag for the NIH Toolbox test being administered, as part of the NIH Toolbox | NIHTBAdminTestFlagInd | Recommended | CDE |
NIH Toolbox Pain Intensity Survey (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Brief Pain Inventory (BPI) - current pain rating scale | Scale rating the pain the subject is feeling right now, as part of the Brief Pain Inventory (BPI) form. | BPICurntPainRtngScale | Recommended | CDE |
| 2 | Brief Pain Inventory (BPI) - average pain rating scale | Scale indicating the rating of the average pain experienced by the subject, as part of the Brief Pain Inventory (BPI) form. | BPIAvgPainRtngScale | Recommended | CDE |
NIH Toolbox Pain Intensity Survey Scoring (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | NIH Toolbox Sensory Domain Pain Measure Pain Intensity Survey (Web, CAT, iPad) - Level of pain intensity score | Score for current pain rating, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Intensity Survey (Web, CAT, iPad) | NIHTBLvlPainIntensityScore | Recommended | CDE |
| 2 | NIH Toolbox - Standard error | Standard error (a statistical measure of variance that represents the margin of error for the Tscore), as part of the NIH Toolbox Web, Cat and iPad Cognition measures such as: Picture Vocabulary Test and Oral Reading Recognition Test. | NIHTBStandardError | Optional | CDE |
Keywords
