Form Structure: Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - do not use
This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - do not use
Short Name:
Rivermead
Description:
Please refer to the latest and greatest RivermeadPCSQ FS.
The Rivermead Post-Concussion Symptoms Questionnaire (RPQ), is a questionnaire that can be administered to someone who sustains a concussion or other form of traumatic brain injury to measure the severity of symptoms. The RPQ is used to determine the presence and severity of post-concussion syndrome - a set of somatic, cognitive, and emotional symptoms following traumatic brain injury (TBI) that may persist anywhere from a week, to months, or even more than six months. References; King, N., Crawford, S., Wenden, F., Moss, N., and Wade, D. (1995) J. Neurology 242: 587-592
Disease:
Traumatic Brain Injury
Organization:
NIH
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-03-02
Version:
1.3
Date Created:
2015-02-23
Owner:
Number of Data Elements:
35
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 |
Questionnaire (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Compared with before the accident, do you now suffer from: headaches? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Headaches scale | RPQHeadachesScale | Recommended | CDE |
| 2 | Compared with before the accident, do you now suffer from: dizziness? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Dizziness scale | RPQDizzinessScale | Recommended | CDE |
| 3 | Compared with before the accident, do you now suffer from: nausea and/or vomiting? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Nausea scale | RPQNauseaScale | Recommended | CDE |
| 4 | Compared with before the accident, do you now suffer from: noise sensitivity (easily upset by loud noise)? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Noise sensitivity scale | RPQNoiseSensScale | Recommended | CDE |
| 5 | Compared with before the accident, do you now suffer from: sleep disturbance? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Sleep disturbance scale | RPQSleepDistScale | Recommended | CDE |
| 6 | Compared with before the accident, do you now suffer from: fatigue, tiring more easily? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Fatigue scale | RPQFatigueScale | Recommended | CDE |
| 7 | Compared with before the accident, do you now suffer from: being irritable, easily angered? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Irritable scale | RPQIrritableScale | Recommended | CDE |
| 8 | Compared with before the accident, do you now suffer from: feeling depressed or tearful? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Depression scale | RPQDepressedScale | Recommended | CDE |
| 9 | Compared with before the accident, do you now suffer from: feeling frustrated or impatient? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Frustrated scale | RPQFrustratedScale | Recommended | CDE |
| 10 | Compared with before the accident, do you now suffer from: forgetfulness, poor memory? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Forgetfulness scale | RPQForgetfulScale | Recommended | CDE |
| 11 | Compared with before the accident, do you now suffer from: poor concentration? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Poor concentration scale | RPQPoorConcScale | Recommended | CDE |
| 12 | Compared with before the accident, do you now suffer from: taking longer to think? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Longer to think scale | RPQLongToThinkScale | Recommended | CDE |
| 13 | Compared with before the accident, do you now suffer from: blurred vision? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Blurred vision scale | RPQBlurredVisionScale | Recommended | CDE |
| 14 | Compared with before the accident, do you now suffer from: light sensitivity (easily upset by bright light)? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Light sensitivity scale | RPQLightSensScale | Recommended | CDE |
| 15 | Compared with before the accident, do you now suffer from: double vision? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Double vision scale | RPQDblVisionScale | Recommended | CDE |
| 16 | Compared with before the accident, do you now suffer from: restlessness? | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Restlessness scale | RPQRestlessScale | Recommended | CDE |
| 17 | Compared with before the accident, are you experiencing any other difficulties? Please specify the first other difficulty and rate as above. | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - First other difficulty scale | RPQOthr1DiffcltyScale | Recommended | CDE |
| 18 | Compared with before the accident, are you experiencing any other difficulties? Please specify, and rate as above. | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - First other difficulty text | RPQOthr1DiffcltyTxt | Recommended | CDE |
| 19 | Compared with before the accident, are you experiencing any other difficulties? Please specify, and rate as above. | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Second other difficulty scale | RPQOthr2DiffcltyScale | Recommended | CDE |
| 20 | Compared with before the accident, are you experiencing any other difficulties? Please specify, and rate as above. | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Second other difficulty text | RPQOthr2DiffcltyTxt | Recommended | CDE |
| 21 | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Sum of the ratings for the first 3 items excluding ratings of 1 | Sum of the ratings for the first three items of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) excluding ratings of 1. | RPQ3Score | Recommended | CDE |
| 22 | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Sum of the ratings for the 13 items (4-16) excluding ratings of 1 | Sum of the ratings for the 13 items (4-16) of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) excluding ratings of 1. | RPQ13Score | Recommended | CDE |
| 23 | The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Sum of the ratings for items 1-16 excluding ratings of 1 | Sum of the ratings for items 1-16 of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) excluding ratings of 1. | RPQTotalScore | Recommended | CDE |
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