Form Structure: Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionnaire
This form structure is an organized set of data definitions for a copyrighted form
Resource:
FITBIR
Title:
Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionnaire
Short Name:
PedsQLPPQ
Description:
The PedsQL 4.0 Measurement Model is a modular approach to measuring health-related quality of life (HRQOL) in healthy children and adolescents and those with acute and chronic health conditions. The PedsQL Pediatric Pain Questionnaire is composed of 3 items. opyright 1998 JW Varni, PhD. All rights reserved. Varni JW, Seid M, Kurtin PD. PedsQL 4.0: Reliability and validity of the pediatric quality of life inventory Version 4.0 generic core scales in healthy and patient populations. Medical Care. 2001; 38(8): 800-12.
Disease:
Traumatic Brain Injury
General (For all diseases)
Organization:
NIH/CIT/BRICS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-11-02
Owner:
Number of Data Elements:
23
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 |
Context Age (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Pediatric Quality of Life Inventory (PedsQL) - AgeRange | Age Range as a part of Pediatric Quality of Life Inventory (PedsQL). | AgeRange | Recommended | CDE |
PedsQL Pediatric Pain Questionnaire (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire - Pain description word text | Free form text entry in words to describe the subject's pain, as a part of the Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire | PedsQLPPQPainDescriptnWrdTxt | Recommended | CDE |
| 2 | Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire - Present pain scale | Scale of how the patient feels right now, as part of the Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire. | PedsQLPPQPresentPainScl | Recommended | CDE |
| 3 | Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire - Worst pain week scale | Scale of the worst pain the patient has felt this week, as part of the Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire. | PedsQLPPQWorstPainWeekScl | Recommended | CDE |
| 4 | Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire - Pain place anatomic site number | Anatomical site indicating exact location of any pain currently being felt by the patient, as part of the Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire. | PedsQLPPQPainPlaceAnatSite | Recommended | CDE |
| 5 | Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire - Pain place anatomic site | Number for the any pain indicated at the anatomic site currently being felt by the patient, as part of the Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire. | PedsQLPPQPainPlaceAnatSiteNum | Recommended | CDE |
| 6 | Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire - Pain color type | Type of the color that corresponds to each level of pain (no pain, mild pain, moderate pain, or severe pain), as a part of the Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire. | PedsQLPPQChildPainColorTyp | Recommended | CDE |
| 7 | Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire - Pain color place anatomic site | Provides the loction of the areas on the body are which color (and therefore which level of pain), as a part of the Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionaire. | PedsQLPPQChildPainColrAnatSite | Recommended | CDE |
Keywords
