Form Structure: Neuro-QoL Lower Extremity Function Long Form
This form structure is an organized set of data definitions for a copyrighted form
Resource:
FITBIR
Title:
Neuro-QoL Lower Extremity Function Long Form
Short Name:
NeuroQoLLwrExtrmtyFnctnLF
Description:
NeuroQoL Lower Extremity Function.Copyright 2008-2013 David Cella and the PROMIS Health Organization on behalf of the National Institute for Neurological Disorders and Stroke (NINDS)
Disease:
General (For all diseases)
Traumatic Brain Injury
Organization:
FITBIR
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-12-28
Owner:
Number of Data Elements:
40
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 | Language form administration ISO code | Code (ISO 639-2) for the language that was used for CRF/instrument/scale/etc. administration | LangCRFAdministratISOCode | Recommended | CDE |
2 | Language form administration ISO code other text | The free-text field related to 'Language used for CRF/instrument/scale/etc. administration ISO code' specifying other text. | LangCRFAdministratISOCodeOTH | Recommended | CDE |
3 | Context type | The context to which the questions were answered | ContextType | Recommended | CDE |
4 | Context type other text | The free-text related to ContextType specifying other text | ContextTypeOTH | Recommended | CDE |
5 | Data source | Source of the data provided on the case report form | DataSource | Recommended | CDE |
6 | 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 |
Lower Extremity Function LF (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Quality of Life - Movement sit stand toilet seat scale | The scale which represents the extent to which the participant was able to get on and off the toilet, as part of Neuro-QOL Lower Extremity Function. | QoLMoveSitStndToiletSeatScl | Recommended | CDE |
2 | Quality of Life - Movement up down step curb ability scale | The scale which represents the extent to which the participant was able to step up and down curbs, as part of Neuro-QOL Lower Extremity Function. | QolMoveUpDownStepCurbAbltyScl | Recommended | CDE |
3 | Quality of Life - Movement in out car ability scale | The scale which represents the extent to which the participant was able to get in and out of the car, as part of Neuro-QOL Lower Extremity Function. | QolMoveInOutCarAbilityScl | Recommended | CDE |
4 | Quality of Life - Movement bed chair ability scale | The scale which represents the extent to which the participant was able to get out of bed into a chair, as part of Neuro-QOL Lower Extremity Function. | QolMoveBedChairAbilityScl | Recommended | CDE |
5 | Quality of Life - Movement push open heavy door ability scale | The scale which represents the extent to which the participant was able to push open a heavy door, as part of Neuro-QOL Lower Extremity Function. | QolMovePshOpnHvyDoorAblityScl | Recommended | CDE |
6 | Quality of Life - Movement errand shop ability scale | The scale which represents the extent to which the participant was able to run errands and shop, as part of Neuro-QOL Lower Extremity Function. | QolMoveErrandShopAbilityScl | Recommended | CDE |
7 | Quality of Life - Movement without assistance floor stand ability scale | The scale which represents the extent to which the participant was able to get up off the floor from lying on their back without help, as part of Neuro-QOL Lower Extremity Function. | QolMoveWthoutAsstnFlrAbltyScl | Recommended | CDE |
8 | Quality of Life - Movement walk fifteen minute duration ability scale | The scale which represents the extent to which the participant was able to go for a walk of at least 15 minutes, as part of Neuro-QOL Lower Extremity Function. | QolMoveWlkFftnMinDurAbltyScl | Recommended | CDE |
9 | Quality of Life - Movement armless straight chair stand up difficulty scale | The scale which represents the amount of difficulty the participant currently has in standing up from an armless straight chair (e.g., dining room chair), as part of Neuro-QOL Lower Extremity Function. | QoLMoveArmlssStrghtChrAbltyScl | Recommended | CDE |
10 | Quality of Life - Movement chair sit stand difficulty scale | The scale which represents the amount of difficulty the participant currently has in sitting down on and standing up from a chair with arms, as part of Neuro-QOL Lower Extremity Function. | QolMoveChrSitStndDifAbltyScl | Recommended | CDE |
11 | Quality of Life - Movement bed sit lay down difficulty scale | The scale which represents the amount of difficulty the participant currently has in moving from sitting at the side of the bed to lying down on their back, as part of Neuro-QOL Lower Extremity Function. | QolMoveBedSitLayDownDiffScl | Recommended | CDE |
12 | Quality of Life - Movement low soft couch stand difficulty scale | The scale which represents the amount of difficulty the participant currently has in standing up from a low, soft couch, as part of Neuro-QOL Lower Extremity Function. | QoLMoveLowSoftCouchStndDiffScl | Recommended | CDE |
13 | Quality of Life - Movement flight stair handrail up down difficulty scale | The scale which represents the amount of difficulty the participant currently has in going up and down a flight of stairs inside, using a handrail, as part of Neuro-QOL Lower Extremity Function. | QolMoveFlghtStrUpDwnDiffScl | Recommended | CDE |
14 | Quality of Life - Movement uneven surface walk difficulty scale | The scale which represents the amount of difficulty the participant currently has in walking on uneven surfaces (e.g., grass, dirt road or sidewalk), as part of Neuro-QOL Lower Extremity Function. | QolMoveUnevenSrfaceWlkDiffScl | Recommended | CDE |
15 | Quality of Life - Movement single floor walk difficulty scale | The scale which represents the amount of difficulty the participant currently has in walking around one floor of their home, as part of Neuro-QOL Lower Extremity Function. | QolMoveSingleFloorWalkDiffScl | Recommended | CDE |
16 | Quality of Life - Movement twenty minute duration brisk walk difficulty scale | The scale which represents the amount of difficulty the participant currently has in taking a 20-minute brisk walk, without stopping to rest, as part of Neuro-QOL Lower Extremity Function. | QoLMoveTwtyMnDrtnBrskWkDiffScl | Recommended | CDE |
17 | Quality of Life - Movement outdoor slippery surface walk difficulty scale | The scale which represents the amount of difficulty the participant currently has in walking on a slippery surface, outdoors, as part of Neuro-QOL Lower Extremity Function. | QoLMoveOutdrSlprySrfcWkDiffScl | Recommended | CDE |
18 | Quality of Life - Movement no handrail stair climb difficulty scale | The scale which represents the amount of difficulty the participant currently has in climbing stairs step over step without a handrail (alternating feet), as part of Neuro-QOL Lower Extremity Function. | QoLMoveNoHandrlStrClmbDiffScl | Recommended | CDE |
19 | Quality of Life - Movement dark room no fall walk difficulty scale | The scale which represents the amount of difficulty the participant currently has in walking in a dark room without falling, as part of Neuro-QOL Lower Extremity Function. | QoLMoveDrkRmNoFallWalkDiffScl | Recommended | CDE |
NeuroQoL Form Administration (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Quality of Life in Neurological Disorders (Neuro-Qol) - Form administered status | The specific Neuro-Qol form administered status, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLFormStatus | Recommended | CDE |
NeuroQol Scoring (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Quality of Life in Neurological Disorders (Neuro-Qol) - Items completed count | The count of items on the Neuro-Qol form completed by the participant, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLItemCompletedCount | Recommended | CDE |
2 | Quality of Life in Neurological Disorders (Neuro-Qol) - Long Form Raw score | The participant's raw score on the Neuro-Qol form, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLLFRawScore | Recommended | CDE |
3 | Quality of Life in Neurological Disorders (Neuro-Qol) - Standard error | Standard error, as part of the Quality of Life in Neurological Disorders (Neuro-Qol) | QoLStandardError | Recommended | CDE |
4 | Quality of Life in Neurological Disorders (Neuro-Qol) - T-score value | The value of the T-score, a standardized score with a mean of 50 and a standard deviation (SD) of 10 representing the rescaled raw score, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).(PROMIS). | QoLTScore | Recommended | CDE |
5 | Quality of Life in Neurological Disorders (Neuro-Qol) - Theta value | Theta metric value reported from the CAT Neuro-Qol results, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLThetaVal | Recommended | CDE |
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