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Form Structure: Patient Health Questionnaire (PHQ)

This form structure is an organized set of data definitions for a form that has not been copyrighted
Resource:
FITBIR
Title:
Patient Health Questionnaire (PHQ)
Short Name:
PHQ
Description:
The PHQ contains the mood (PHQ-9), anxiety, alcohol, eating, and somatoform modules. References: http://www.phqscreeners.com/ Recommended by CDISC for TBI, (TAUG TBI)
Disease:
General (For all diseases)
Organization:
NIH
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-06-22
Version:
1.2
Date Created:
2015-06-08
Owner:
Number of Data Elements:
81
eForms:
Y
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.

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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

Pain (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Patient Health Questionnaire (PHQ) - Stomach pain problem past 4 weeks score  Score of stomach pain in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQStomachPainScore Recommended CDE
2 Patient Health Questionnaire (PHQ) - Back pain problem past 4 weeks score  Score of back pain in the past 4 week, as part of the Patient Health Questionnaire (PHQ). PHQBackPainScore Recommended CDE
3 Patient Health Questionnaire (PHQ) - Arm, leg joint pain problem past 4 weeks score  Score of pain in your arms legs or joints (knees hips etc.) in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQPainArmLegJointsScore Recommended CDE
4 Patient Health Questionnaire (PHQ) - Dysmenorrhea problem past 4 weeks score  Score of menstrual cramps or other problems with your periods in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQMenstrualCrampProbScore Recommended CDE
5 Patient Health Questionnaire (PHQ) - Sexual intercourse pain problem past 4 weeks score  Score of pain or problems during sexual intercourse in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQPainProblemSexScore Recommended CDE
6 Patient Health Questionnaire (PHQ) - Headache problem past 4 weeks score  Score of headaches in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQHeadacheScore Recommended CDE
7 Patient Health Questionnaire (PHQ) - Chest pain problem past 4 weeks score  Score of chest pain in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQChestPainScore Recommended CDE
8 Patient Health Questionnaire (PHQ) - Dizziness problem past 4 weeks score  Score of dizziness in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQDizzinessScore Recommended CDE
9 Patient Health Questionnaire (PHQ) - Fainting spells (Syncope) problem past 4 weeks score  Score of fainting spells in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQFaintingSpellScore Recommended CDE
10 Patient Health Questionnaire (PHQ) - Tachycardia (racing heart ) problem past 4 weeks score  Score of racing heart in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQRacingHeartScore Recommended CDE
11 Patient Health Questionnaire (PHQ) - Dyspnea (shortness of breath) problem past 4 weeks score  Score of shortness of breath in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQShortnessOfBreathScore Recommended CDE
12 Patient Health Questionnaire (PHQ) - Constipation problem past 4 weeks score  Score of constipation in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQConstipationScore Recommended CDE
13 Patient Health Questionnaire (PHQ) - Nausea indigestion problem past 4 weeks score  Score of Nausea gas or indigestion in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQNauseaIndigestionScore Recommended CDE
14 Patient Health Questionnaire (PHQ) - Somatoform disorder indicator  Indicator of whether or not the subject met the diagnostic criteria for somatoform disorder, as part of the Patient Health Questionnaire (PHQ). PHQSomDisInd Recommended CDE

Mood (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Patient Health Questionnaire (PHQ9) - Little interest score  Score of how much the subject has been bothered by having little interest or pleasure in doing things in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9IntrstPleasrActScore Recommended CDE
2 Patient Health Questionnaire (PHQ9) - Depressed score  Score of how much the subject has been feeling down and depressed in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9DwnDeprssnHopelssScore Recommended CDE
3 Patient Health Questionnaire (PHQ9) - Sleep impairment score  Score of how much the subject has been bothered with troubling falling/staying asleep or sleeping too much in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9SleepImpairScore Recommended CDE
4 Patient Health Questionnaire (PHQ9) - Tired little energy score  Score of how much the subject has been feeling tired in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9TirdLittleEnrgyScore Recommended CDE
5 Patient Health Questionnaire (PHQ9) - Abnormal diet score  Score of how much the subject has been bothered by abnormal diet/appetite in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9AbnrmlDietScore Recommended CDE
6 Patient Health Questionnaire (PHQ9) - Feeling failure score  Score of how much the subject has been feeling bad for himself/herself in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9FlngFailrScore Recommended CDE
7 Patient Health Questionnaire (PHQ9) - Concentration impairment score  Score of how much the subject has been bothered with troubling concentrating in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9ConcntrtnImprmntScore Recommended CDE
8 Patient Health Questionnaire (PHQ9) - Movement speech impairment score  Score of how much the subject has been suffering with moving or speaking too slowly in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9MovmntSpchImprmntScore Recommended CDE
9 Patient Health Questionnaire (PHQ9) - Better dead thought score  Score of how much the subject has been suffering with the thoughts of that he/she would be better off dead to hurt in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9BttrDdThghtScore Recommended CDE
10 Patient Health Questionnaire (PHQ9) - Difficulty performing scale  Scale of how difficult it is to do work, take care of things at home, or get along with other people for the subject in the past two weeks, as the part of Patient Health Questionnaire Depression (PHQ). PHQ9DiffcltyPerfActScre Recommended CDE
11 Patient Health Questionnaire (PHQ) - Major depressive syndrome indicator  Indicator of whether or not the subject met the diagnostic criteria for major depressive syndrome, as part of the Patient Health Questionnaire (PHQ). PHQMajDepSynInd Recommended CDE
12 Patient Health Questionnaire (PHQ) - Other depressive syndrome indicator  Indicator of whether or not the subject met the diagnostic criteria for other depressive syndrome, as part of the Patient Health Questionnaire (PHQ). PHQOtherDepSynInd Recommended CDE
13 Patient Health Questionnaire (PHQ) - Depression score greater 10  Indication of depression score being greater than 10, as part of the Patient Health Questionnaire (PHQ). PHQDepressionGtr10Ind Recommended CDE

Anxiety (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Patient Health Questionnaire (PHQ) - Anxiety attack fear panic past 4 weeks indicator  Indication of an anxiety attack--suddenly feeling fear or panic in the last 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackInd Recommended CDE
2 Patient Health Questionnaire (PHQ) - Anxiety prior occurrence indicator  Indication of an anxiety attack before, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackBeforeInd Recommended CDE
3 Patient Health Questionnaire (PHQ) - Anxiety attack sometimes sudden indicator  Indication of an sudden anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackSuddenInd Recommended CDE
4 Patient Health Questionnaire (PHQ) - Anxiety attack bother worry repeat indicator  Indication of worrying or bothered by anxiety attacks, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackBotherWorryInd Recommended CDE
5 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack short of breath (dyspnea) indicator  Indication of being short of breath while experiencing an anxiety attacks, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackShortBreathInd Recommended CDE
6 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack tachycardia indicator  Indication of the heart race pound or skipping while experiencing an anxiety attacks, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackHeartRaceInd Recommended CDE
7 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack chest pain indicator  Indication of chest pain or pressure pain while experiencing an anxiety attacks, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackChestPainInd Recommended CDE
8 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack sweat indicator  Indication of sweating when experiencing an anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackSweatInd Recommended CDE
9 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack choking indicator  Indication of the feel of choking when experiencing an anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackChokeInd Recommended CDE
10 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack hot flash chill indicator  Indication of hot flashes or chills when experiencing an anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackHotColdInd Recommended CDE
11 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack of nausea or diarrhea indicator  Indication of nausea upset stomach or diarrhea when experiencing an anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackNauseaInd Recommended CDE
12 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack dizziness indicator  Indication of feeling dizzy unsteady or faint when experiencing an anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackDizzyInd Recommended CDE
13 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack tingle numb indicator  Indication of tingling or numbness when experiencing an anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackTingleNumbInd Recommended CDE
14 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack tremble indicator  Indication of trembling or shaking when experiencing an anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackTrembleInd Recommended CDE
15 Patient Health Questionnaire (PHQ) - Most recent severe anxiety attack death fear indicator  Indication of feeling afraid of dying when experiencing an anxiety attack, as part of the Patient Health Questionnaire (PHQ). PHQAnxietyAttackAfraidDyingInd Recommended CDE
16 Patient Health Questionnaire (PHQ) - Panic syndrome indicator  Indicator of whether or not the subject met the diagnostic criteria for panic syndrome, as part of the Patient Health Questionnaire (PHQ). PHQPanSynInd Recommended CDE
17 Patient Health Questionnaire (PHQ) - Nervous anxious problem past 4 weeks score  Indication of feeling nervous anxious on edge or worrying a lot about different in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQFeelNervousAnxiousScore Recommended CDE
18 Patient Health Questionnaire (PHQ) - Restless problem past 4 weeks score  Score of feeling restless in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQFeelRestlessScore Recommended CDE
19 Patient Health Questionnaire (PHQ) - Easy tired problem past 4 weeks score  Score of getting tired easily in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQGetTiredEasyScore Recommended CDE
20 Patient Health Questionnaire (PHQ) - Muscle tension problem past 4 weeks score  Score of muscle tension or ache in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQMuscleTensionScore Recommended CDE
21 Patient Health Questionnaire (PHQ) - Sleep impairment problem past 4 weeks score  Score of trouble falling or staying asleep or sleeping too much in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQTroubleFallAsleepScore Recommended CDE
22 Patient Health Questionnaire (PHQ) - Trouble concentration problem past 4 weeks score  Score of trouble concentrating in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQTroubleConcentrateScore Recommended CDE
23 Patient Health Questionnaire (PHQ) - Easy annoy irritate problem past 4 weeks score  Score of becoming easily annoyed or irritated in the past 4 weeks, as part of the Patient Health Questionnaire (PHQ). PHQEasilyAnnoyIrritateScore Recommended CDE
24 Patient Health Questionnaire (PHQ) - Other anxiety syndrome indicator  Indicator of whether or not the subject met the diagnostic criteria for other anxiety syndrome, as part of the Patient Health Questionnaire (PHQ). PHQOtherAnxSynInd Recommended CDE

Eating (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Patient Health Questionnaire (PHQ) - Cannot control eating indicator  Indication of not controlling what or how much you eat, as part of the Patient Health Questionnaire (PHQ). PHQCantControlEatingInd Recommended CDE
2 Patient Health Questionnaire (PHQ) - Regularly eat large amount indicator  Indication of eating within any 2-hour period what most people would regard as an unusually large amount of food, as part of the Patient Health Questionnaire (PHQ). PHQEatLargeAmountInd Recommended CDE
3 Patient Health Questionnaire (PHQ) - Regularly eat large amount at least twice weekly indicator  Indication of eating within any 2-hour period what most people would regard as an unusually large amount of food twice a week, as part of the Patient Health Questionnaire (PHQ). PHQEatLargeAmountTwiceWkInd Recommended CDE
4 Patient Health Questionnaire (PHQ) - Action avoid weight gain self induced vomit indicator  Indication making self vomit, as part of the Patient Health Questionnaire (PHQ). PHQMadeYourselfVomitInd Recommended CDE
5 Patient Health Questionnaire (PHQ) - Action avoid weight gain twice dose laxative use indicator  Indication of taking more than twice the recommended dose of laxatives, as part of the Patient Health Questionnaire (PHQ). PHQTwiceDoseLaxativeInd Recommended CDE
6 Patient Health Questionnaire (PHQ) - Action to avoid weight gain (fasting) indicator  Indication of fasting (not eaten anything at all for at least 24 hours), as part of the Patient Health Questionnaire (PHQ). PHQFastedInd Recommended CDE
7 Patient Health Questionnaire (PHQ) - Action avoid weight gain exercise indicator  Indication of exercising for more than an hour specifically to avoid gaining weight after binge eating, as part of the Patient Health Questionnaire (PHQ). PHQExerciseAvoidWgtGainInd Recommended CDE
8 Patient Health Questionnaire (PHQ) - Action avoid weight gain at least twice week indicator  Indication of avoiding gaining weight were any as often on average as twice a week, as part of the Patient Health Questionnaire (PHQ). PHQAvoidWgtGainTwiceWkInd Recommended CDE
9 Patient Health Questionnaire (PHQ) - Bulimia nervosa indicator  Indicator of whether or not the subject met the diagnostic criteria for bulimia nervosa, as part of the Patient Health Questionnaire (PHQ). PHQBulNerInd Recommended CDE
10 Patient Health Questionnaire (PHQ) - Binge eating disorder indicator  Indicator of whether or not the subject met the diagnostic criteria for binge eating disorder, as part of the Patient Health Questionnaire (PHQ). PHQBinEatDisInd Recommended CDE

Alcohol (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Patient Health Questionnaire (PHQ) - Alcohol consumption indicator  Indication of drinking alcohol (including beer or wine), as part of the Patient Health Questionnaire (PHQ). PHQDrinkAlcInd Recommended CDE
2 Patient Health Questionnaire (PHQ) - Alcohol consumption against physician direction past 6 months indicator  Indication of drinking alcohol even though a doctor suggested that you stop drinking because of a problem with your health, as part of the Patient Health Questionnaire (PHQ). PHQDrinkAlcDoctorStopInd Recommended CDE
3 Patient Health Questionnaire (PHQ) - Alcohol consumption while work family school responsibility indicator  Indication of drinking alcohol were high from alcohol or were hung over while you were working going to school or taking care of children or other responsibilities, as part of the Patient Health Questionnaire (PHQ). PHQDrinkAlcResponsibilitiesInd Recommended CDE
4 Patient Health Questionnaire (PHQ) - Alcohol consumption cause work, family, or school lateness indicator  Indication of missing or were late for work school or other activities because you were drinking or hung over, as part of the Patient Health Questionnaire (PHQ). PHQDrinkAlcLateInd Recommended CDE
5 Patient Health Questionnaire (PHQ) - Alcohol use concurrent problem with other people indicator  Indication of having a problem getting along with other people while you were drinking, as part of the Patient Health Questionnaire (PHQ). PHQDrinkAlcGetAlongOthersInd Recommended CDE
6 Patient Health Questionnaire (PHQ) - Driving intoxicated past 6 months indicator  Indication of driving a car after having several drinks or after drinking too much, as part of the Patient Health Questionnaire (PHQ). PHQDrinkAlcDriveInd Recommended CDE
7 Patient Health Questionnaire (PHQ) - Alcohol abuse indicator  Indicator of whether or not the subject met the diagnostic criteria for alcohol abuse, as part of the Patient Health Questionnaire (PHQ). PHQAlcAbuInd Recommended CDE

Difficulty performing scale (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Difficulty performing scale  Scale of how difficult reported problems are, as part of Patient Health (PHQ, PHQ2, PHQ8,PHQ9, PHQ15) and Generalized Anxiety Disorder (GAD-7) Questionnaires PHQDiffcltyPerfActScore Recommended CDE
Keywords