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

 General Details

Title:
NIH Toolbox Sensation Domain Pain Interference Survey
Short Name:
NIHTBPainInterferSurvey
Description:
Sensation Domain: The NIH Toolbox Pain Interference Survey is a brief, self-report scale that measures the degree to which pain interferes with other activities in the lives of adults. Pain Interference items were developed as part of NIH PROMIS. This measure is administered as a computer-adaptive test and takes approximately three minutes to complete. It is recommended for ages 18-85. This test is part of the NIH Toolbox Sensory Domain Pain Measure.
Disease:
Traumatic Brain Injury
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2016-07-01
Version:
1.0
Date Created:
2016-05-18
Owner:
Number of Data Elements:
43
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 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

NIH ToolBox Administration (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox - Test domain battery type  Type of domain battery for the NIH Toolbox test being administered, as a part of the NIH Toolbox NIHTBTestDomainBatteryTyp Recommended CDE
2 NIH Toolbox - Test domain battery type other  The free-text related to NIHTBTestDomainBatteryTyp specifying other text, as part of the NIH Toolbox NIHTBTestDomainBatteryTypOTH Recommended CDE
3 NIH Toolbox - Test name type  Type of NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestNameTyp Recommended CDE
4 NIH Toolbox - Test name type other  The free-text related to NIHTBAdminTestNameTyp specifying other text, as part of the NIH Toolbox NIHTBAdminTestNameTypOTH Recommended CDE
5 NIH Toolbox - Test administration language type  Type of language for test being administrated, as part of the NIH Toolbox NIHTBTestAdminLanguageTyp Recommended CDE
6 NIH Toolbox - Test administration language type other  Free-text related to NIHTBTestAdminLanguageTyp specifying other text, as part of the NIH Toolbox NIHTBTestAdminLanguageTypOTH Recommended CDE
7 NIH Toolbox - Form administered type  Type of NIH Toolbox form being administered, as part of the NIH Toolbox NIHTBFormAdminTyp Recommended CDE
8 NIH Toolbox - Test administration flag type  Type of flag for the NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestFlagTyp Recommended CDE
9 NIH Toolbox - Test administration flag indicator  Indicator of a flag for the NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestFlagInd Recommended CDE

NIH Toolbox Pain Interference Survey (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Lowest level of pain scale  Scale of lowest level of pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain interference Survey NIHTBPILowLvlPainIntScl Recommended CDE
2 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain at its worst scale  Scale of pain at its worst, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIWorstPainIntScl Recommended CDE
3 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Intolerable pain frequency scale  Scale of frequency of pain feeling intolerable, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIIntolerablPainFreqScl Recommended CDE
4 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Angry when in pain scale  Scale for feeling angry when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIAngryPainScl Recommended CDE
5 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Trouble with schoolwork when in pain scale  Scale for having trouble doing schoolwork when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPITrblSchoolworkPainScl Recommended CDE
6 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Trouble sleeping when in pain scale  Scale for having trouble sleeping when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPITrblSleepPainScl Recommended CDE
7 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to pay attention when in pain scale  Scale for how hard it was to pay attention when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIHardPayAttnPainScl Recommended CDE
8 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to run when in pain scale  Scale for how hard it was to run when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIHardRunPainScl Recommended CDE
9 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to walk one block when in pain scale  Scale for how hard it was to walk one block when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIHrdWlk1BlkPainScl Recommended CDE
10 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to have fun when in pain scale  Scale for how hard it was to have fun when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIHardHavFunPainScl Recommended CDE
11 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Hard to stay standing when in pain scale  Scale for how hard it was to stay standing when in pain, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIHardStayStandPainScl Recommended CDE
12 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with daily activities scale  Scale for how much pain interfered with day to day activities, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIPainIntDailyActScl Recommended CDE
13 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with housework scale  Scale for how much pain interfered with work around the home, in the passt 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIPainIntHouseworkScl Recommended CDE
14 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with social activities participation scale  Scale for how much pain interfered with the ability to participate in social activities, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIPainIntPrtcpSocActScl Recommended CDE
15 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with chores scale  Scale for how much pain interfered with household chores, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIPainIntChoresScl Recommended CDE
16 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with fun activities scale  Scale for how much pain interfered with things usually done for fun, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIPainIntFunActScl Recommended CDE
17 NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey - Pain interfered with social activities enjoyment scale  Scale for how much pain interfered with enjoyment of social activities, in the past 7 days, as part of the NIH Toolbox Sensory Domain Pain Measure Pain Interference Survey NIHTBPIPainIntEnjoySocActScl Recommended CDE

NIH Toolbox Pain Interference Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Patient-Reported Outcome Measure Information System (PROMIS) - theta value  The value of theta reported from the CAT PROMIS results, as part of the Patient-Reported Outcome Measurement Information System (PROMIS). PROMISTheta Recommended CDE
2 Patient-Reported Outcome Measure Information System (PROMIS) - T-score value  The T-score value, a standardized score with a mean of 50 and standard deviation of 10 representing the rescaled raw score, as part of the Patient-Reported Outcome Measurement Information System. PROMISTScore Recommended CDE
3 Patient-Reported Outcome Measure Information System (PROMIS) - raw score  The participant's raw score on the PROMIS form, as part of the Patient-Reported Outcome Measurement Information System (PROMIS). PROMISRawScore Recommended CDE
4 Patient-Reported Outcome Measure Information System (PROMIS) - Standard error  Standard error, as part of the Patient-Reported Outcome Measurement Information System (PROMIS) PROMISStandardError Recommended CDE

 Change History

 Administrative Change History