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.
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