Form Structure: NIH Toolbox Sensation Domain Pain Interference Survey
This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
NIH Toolbox Sensation Domain Pain Interference Survey
Short Name:
NIHTBPainInterferSurvey
Description:
Sensation Domain: The NIH Toolbox Pain Interference Survey is a brief, self-report scale that measures the degree to which pain interferes with other activities in the lives of adults. Pain Interference items were developed as part of NIH PROMIS. This measure is administered as a computer-adaptive test and takes approximately three minutes to complete. It is recommended for ages 18-85. This test is part of the NIH Toolbox Sensory Domain Pain Measure.
Disease:
Traumatic Brain Injury
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2016-07-01
Version:
1.0
Date Created:
2016-05-18
Owner:
Number of Data Elements:
43
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 (Repeat Infinitely)
| # | 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 Interference Survey (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Lowest level of pain scale | Scale of lowest level of pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain interference Survey | NIHTBPILowLvlPainIntScl | Recommended | CDE |
| 2 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain at its worst scale | Scale of pain at its worst, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIWorstPainIntScl | Recommended | CDE |
| 3 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Intolerable pain frequency scale | Scale of frequency of pain feeling intolerable, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIIntolerablPainFreqScl | Recommended | CDE |
| 4 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Angry when in pain scale | Scale for feeling angry when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIAngryPainScl | Recommended | CDE |
| 5 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Trouble with schoolwork when in pain scale | Scale for having trouble doing schoolwork when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPITrblSchoolworkPainScl | Recommended | CDE |
| 6 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Trouble sleeping when in pain scale | Scale for having trouble sleeping when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPITrblSleepPainScl | Recommended | CDE |
| 7 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to pay attention when in pain scale | Scale for how hard it was to pay attention when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIHardPayAttnPainScl | Recommended | CDE |
| 8 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to run when in pain scale | Scale for how hard it was to run when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIHardRunPainScl | Recommended | CDE |
| 9 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to walk one block when in pain scale | Scale for how hard it was to walk one block when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIHrdWlk1BlkPainScl | Recommended | CDE |
| 10 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to have fun when in pain scale | Scale for how hard it was to have fun when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIHardHavFunPainScl | Recommended | CDE |
| 11 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to stay standing when in pain scale | Scale for how hard it was to stay standing when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIHardStayStandPainScl | Recommended | CDE |
| 12 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with daily activities scale | Scale for how much pain interfered with day to day activities, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIPainIntDailyActScl | Recommended | CDE |
| 13 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with housework scale | Scale for how much pain interfered with work around the home, in the passt 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIPainIntHouseworkScl | Recommended | CDE |
| 14 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with social activities participation scale | Scale for how much pain interfered with the ability to participate in social activities, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIPainIntPrtcpSocActScl | Recommended | CDE |
| 15 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with chores scale | Scale for how much pain interfered with household chores, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIPainIntChoresScl | Recommended | CDE |
| 16 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with fun activities scale | Scale for how much pain interfered with things usually done for fun, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIPainIntFunActScl | Recommended | CDE |
| 17 | NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with social activities enjoyment scale | Scale for how much pain interfered with enjoyment of social activities, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey | NIHTBPIPainIntEnjoySocActScl | Recommended | CDE |
NIH Toolbox Pain Interference Scoring (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Patient-Reported Outcome Measure Information System (PROMIS) - theta value | The value of theta reported from the CAT PROMIS results, as part of the Patient-Reported Outcome Measurement Information System (PROMIS). | PROMISTheta | Recommended | CDE |
| 2 | Patient-Reported Outcome Measure Information System (PROMIS) - T-score value | The T-score value, a standardized score with a mean of 50 and standard deviation of 10 representing the rescaled raw score, as part of the Patient-Reported Outcome Measurement Information System. | PROMISTScore | Recommended | CDE |
| 3 | Patient-Reported Outcome Measure Information System (PROMIS) - raw score | The participant's raw score on the PROMIS form, as part of the Patient-Reported Outcome Measurement Information System (PROMIS). | PROMISRawScore | Recommended | CDE |
| 4 | Patient-Reported Outcome Measure Information System (PROMIS) - Standard error | Standard error, as part of the Patient-Reported Outcome Measurement Information System (PROMIS) | PROMISStandardError | Recommended | CDE |
Keywords
