This form structure is an organized set of data definitions for a form that has not been copyrighted

 General Details

Title:
Mayo-Portland Adaptability Inventory-4 (MPAI-4)
Short Name:
MPAI4
Description:
The Mayo-Portland Adaptability Inventory (MPAI) was primarily designed: - to assist in the clinical evaluation of people during the postacute (posthospital) period following acquired brain injury (ABI), and - to assist in the evaluation of rehabilitation programs designed to serve these people. Refer to : Malec, J. (2005). The Mayo Portland Adaptability Inventory. The Center for Outcome Measurement in Brain Injury. Jacob Kean et al, Rasch Measurement Analysis of the Mayo-Portland Adaptability Inventory (MPAI-4) in a Community-Based Rehabilitation Sample, J Neurotrauma. 2011 May; 28(5): 745–753. doi: 10.1089/neu.2010.1573, PMCID: PMC3088961 Recommended by CDISC for TBI (TAUG TBI)
Disease:
Traumatic Brain Injury
Organization:
NINDS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2017-03-30
Version:
1.2
Date Created:
2014-05-28
Owner:
Number of Data Elements:
71
eForms:
N

 Documentation


 Groups & Attached Data Elements

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 Administation (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

Abilities (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Mayo-Portland Adaptability Inventory (MPAI-4) -mobility scale  Mobility: Problems walking or moving; balance problems that interfere with moving about MPAI4MobilityScale Optional CDE
2 Mayo-Portland Adaptability Inventory (MPAI-4) - use hand scale  Use of hands: Impaired strength or coordination in one or both hands, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4UseHandScale Optional CDE
3 Mayo-Portland Adaptability Inventory (MPAI-4) - vision scale  Description of level at which the patient/subject experiences vision problems including problems seeing, double vision, eye, brain or nerve injuries that interfere with seeing, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4VisScale Optional CDE
4 Mayo-Portland Adaptability Inventory (MPAI-4) - audition scale  Description of level at which the patient/subject experiences audition problems including problems hearing; ringing in the ears, as [art pf the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4AudScale Optional CDE
5 Mayo-Portland Adaptability Inventory (MPAI-4) - dizziness scale  Description of level at which the patient/subject experiences dizziness problems including feeling unsteady, dizzy, light-headed, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4DizScale Optional CDE
6 Mayo-Portland Adaptability Inventory (MPAI-4) - motor speech scale  Description of level at which the patient/subject experiences motor speech problems including abnormal clearness or rate of speech; stuttering, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4MotSpeechScale Optional CDE
7 Mayo-Portland Adaptability Inventory (MPAI-4) - verbal communication scale  Description of level at which the patient/subject experiences verbal communication problems including problems expressing or understanding language, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4VerbCommunScale Optional CDE
8 Mayo-Portland Adaptability Inventory (MPAI-4) - nonverbal communication scale  Description of level at which the patient/subject experiences nonverbal communication problems, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4NonverbCommunScale Optional CDE
9 Mayo-Portland Adaptability Inventory (MPAI-4) - attention concentration scale  Description of level at which the patient/subject experiences attention/concentration problems, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4AttenConcenScale Optional CDE
10 Mayo-Portland Adaptability Inventory (MPAI-4) - memory scale  Description of level at which the patient/subject experiences memory problems including problems learning and recalling new information, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4MemryScale Optional CDE
11 Mayo-Portland Adaptability Inventory (MPAI-4) - information fund scale  Description of level at which the patient/subject experiences fund of information problems including problems remembering information learned in school or on the job; as part of the Mayo-Portland Adaptability Inventory (MPAI-4). MPAI4InfoFundScale Optional CDE
12 Mayo-Portland Adaptability Inventory (MPAI-4) - novel problem solve scale  Description of level at which the patient/subject experiences novel problem solving problems including problems thinking up solutions or picking the best solution to new problems, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4NovProbSlvScale Optional CDE
13 Mayo-Portland Adaptability Inventory (MPAI-4) - visuospatial ability scale  Description of level at which the patient/subject experiences visuospatial ability problems, as part of the Mayo-Portland Adaptability Inventory (MPAI-4). MPAI4VisspatAblScale Optional CDE

Adjustment (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Mayo-Portland Adaptability Inventory (MPAI-4) - anxiety scale  Description of level at which the patient/subject experiences anxiety problems including being tense nervous, fearful or having phobias, nightmares, flashbacks of stressful events as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4AnxtylScale Optional CDE
2 Mayo-Portland Adaptability Inventory (MPAI-4) - depression scale  Description of level at which the patient/subject experiences depression problems including being sad, blue, hopeless, having poor appetite, poor sleep, worry, self-criticism as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4DeprsnScale Optional CDE
3 Mayo-Portland Adaptability Inventory (MPAI-4) - irritability anger aggression scale  Description of level at which the patient/subject experiences irritability, anger, aggression problems including verbal or physical expressions of anger, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4IrritAngAgrsnScale Optional CDE
4 Mayo-Portland Adaptability Inventory (MPAI-4) - pain headache scale  Description of level at which the patient/subject experiences pain and headache problems including verbal and nonverbal expressions of pain; activities limited by pain, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PainHeadachScale Optional CDE
5 Mayo-Portland Adaptability Inventory (MPAI-4) - fatigue scale  Description of level at which the patient/subject experiences fatigue problems including feeling tired; lack of energy; tiring easily as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4FatgeScale Optional CDE
6 Mayo-Portland Adaptability Inventory (MPAI-4) - mild symptom sensitivity scale  Description of level at which the patient/subject experiences sensitivity to mild symptoms problems including focusing on thinking, physical or emotional problems attributed to brain injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4MldSymptmSensScale Optional CDE
7 Mayo-Portland Adaptability Inventory (MPAI-4) - inappropriate social scale  Description of level at which the patient/subject experiences inappropriate social interaction problems including acting childish, silly, rude, behavior not fitting for time and place, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4InApprSocInterScale Optional CDE
8 Mayo-Portland Adaptability Inventory (MPAI-4) - impaired self awareness scale  Description of level at which the patient/subject experiences impaired self-awareness problems, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4ImprdSelfawrnesScale Optional CDE
9 Mayo-Portland Adaptability Inventory (MPAI-4) - family relationship scale  Description of the stress level at which the patient/subject experiences family/significant relationship issues including interactions with close others, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4FmlyRelateScale Optional CDE

Participation (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Mayo-Portland Adaptability Inventory (MPAI-4) - initiation scale  Description of level at which the participant/subject experiences problems with initiation including problems getting started on activities without prompting, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4InitScale Optional CDE
2 Mayo-Portland Adaptability Inventory (MPAI-4) - social contact scale  Description of level at which the participant/subject experiences problems with social contact with friends, work associates, and people who are not family, significant others or professionals, as part of the Mayo-Portland Adaptability Inventory (MPAI-4). MPAI4SoclContScale Optional CDE
3 Mayo-Portland Adaptability Inventory (MPAI-4) - leisure scale  Description of level at which the participant/subject experiences problems with leisure and recreational activities, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4LeisScale Optional CDE
4 Mayo-Portland Adaptability Inventory (MPAI-4) - self care scale  Description of level at which the participant/subject experiences problems with self-care including eating, dressing, bathing, hygiene, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4SelfcareScale Optional CDE
5 Mayo-Portland Adaptability Inventory (MPAI-4) - residence scale  Description of level at which the participant/subject experiences problems with residence including responsibilities of independent living and homemaking as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4ResdnceScale Optional CDE
6 Mayo-Portland Adaptability Inventory (MPAI-4) - transportation scale  Description of level at which the participant/subject experiences problems with transportation, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4TrsptScale Optional CDE
7 Mayo-Portland Adaptability Inventory (MPAI-4) - paid employment scale  Description of level at which the participant/subject experiences problems with paid employment, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PaidEmplmtScale Optional CDE
8 Mayo-Portland Adaptability Inventory (MPAI-4) - other employment scale  Description of level at which the participant/subject experiences problems with other employment for example involved in constructive, role-appropriate activity other than paid employment, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4OthrEmplmtScale Optional CDE
9 Mayo-Portland Adaptability Inventory (MPAI-4) - primary social role name  Primary desired social role for other employment of participant/subject, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PrimrySoclRoleName Optional CDE
10 Mayo-Portland Adaptability Inventory (MPAI-4) - manage money scale  Description of level at which the participant/subject experiences problems with managing money and finances, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4MngMnyScale Optional CDE

Pre-existing and Associated Conditions (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Mayo-Portland Adaptability Inventory (MPAI-4) - pre alcohol use scale  Use of alcoholic beverages by the participant/subject after the injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PreAlcUseScale Optional CDE
2 Mayo-Portland Adaptability Inventory (MPAI-4) - post alcohol use scale  Use of alcoholic beverages by the participant/subject after the injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PostAlcUseScale Optional CDE
3 Mayo-Portland Adaptability Inventory (MPAI-4) - pre drug use scale  Use of illegal drugs or abuse of prescription drugs by the participant/subject pre-injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PreDrugUseScale Optional CDE
4 Mayo-Portland Adaptability Inventory (MPAI-4) - post drug use scale  Use of illegal drugs or abuse of prescription drugs by the participant/subject post-injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PostDrugUseScale Optional CDE
5 Mayo-Portland Adaptability Inventory (MPAI-4) - pre psychotic symptom scale  Hallucinations, delusions, other persistent severely distorted perceptions of reality experienced by the participant/subject before the injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PrePyschSymptmScale Optional CDE
6 Mayo-Portland Adaptability Inventory (MPAI-4) - post psychotic symptom scale  Hallucinations, delusions, other persistent severely distorted perceptions of reality experienced by the participant/subject after the injury as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PstPyschSymptmScale Optional CDE
7 Mayo-Portland Adaptability Inventory (MPAI-4) - pre law violation scale  History of law violations of participant/subject before the injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PreLawViolScale Optional CDE
8 Mayo-Portland Adaptability Inventory (MPAI-4) - post law violation scale  History of law violations of participant/subject after the injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PstLawViolScale Optional CDE
9 Mayo-Portland Adaptability Inventory (MPAI-4) - pre other physical impairment scale  Description of other condition causing physical impairment for participant/subject including physical disability due to medical conditions other than brain injury before the injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PreOthrPhysImpairScale Optional CDE
10 Mayo-Portland Adaptability Inventory (MPAI-4) - post other physical impairment scale  Description of other condition causing physical impairment for participant/subject including physical disability due to medical conditions other than brain injury after the injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PstOthrPhysImpairScale Optional CDE
11 Mayo-Portland Adaptability Inventory (MPAI-4) - pre other cognitive impairment scale  Description of other condition causing cognitive impairment for participant/subject including cognitive disability due to nonpsychiatric medical conditions other than brain injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PreOthrCogImpair Optional CDE
12 Mayo-Portland Adaptability Inventory (MPAI-4) - post other cognitive impairment scale  Description of other condition causing cognitive impairment for participant/subject including cognitive disability due to nonpsychiatric medical conditions other than brain injury, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PstOthrCogImpair Optional CDE

Scores (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Mayo-Portland Adaptability Inventory (MPAI-4) - Adjustment raw score  MPAI-4 Adjustment raw score MPAI4AdjSubscaleRawScore Recommended CDE
2 Mayo-Portland Adaptability Inventory (MPAI-4) - Adjustment standard score  MPAI-4 Adjustment Standard score, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4AdjSubscaleScore Optional CDE
3 Mayo-Portland Adaptability Inventory (MPAI-4) - Adjustment T-score  MPAI-4 Adjustment T-score MPAI4AdjSubscaleTScore Recommended CDE
4 Mayo-Portland Adaptability Inventory (MPAI-4) - Ability raw score  MPAI-4 Ability raw score MPAI4AblSubscaleRawScore Recommended CDE
5 Mayo-Portland Adaptability Inventory (MPAI-4) - Ability standard score  MPAI-4 Ability Standard score, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4AblSubscaleScore Optional CDE
6 Mayo-Portland Adaptability Inventory (MPAI-4) - Ability T-score  MPAI-4 Ability T-score MPAI4AblSubscaleTScore Recommended CDE
7 Mayo-Portland Adaptability Inventory (MPAI-4) - Participation raw score  MPAI-4 Participation raw score MPAI4PrtpSubscaleRawScore Recommended CDE
8 Mayo-Portland Adaptability Inventory (MPAI-4) - Participation standard score  MPAI-4 Participation Standard score, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4PrtpSubscaleScore Optional CDE
9 Mayo-Portland Adaptability Inventory (MPAI-4) - Participation T-score  MPAI-4 Participation T-score MPAI4PrtpSubscaleTScore Recommended CDE
10 Mayo-Portland Adaptability Inventory (MPAI-4) - Total raw score  MPAI-4 Total raw score, as part of the Mayo-Portland Adaptability Inventory (MPAI-4) MPAI4TotlRawScore Optional CDE
11 Mayo-Portland Adaptability Inventory (MPAI-4) - Total standard score  MPAI-4 Total standard score MPAI4TotlStandardScore Recommended CDE
12 Mayo-Portland Adaptability Inventory (MPAI-4) - Total T-score  MPAI-4 Total T-score MPAI4TotTScore Recommended CDE

 Change History

 Administrative Change History