This form structure is an organized set of data definitions for a copyrighted form

 General Details

Title:
Neuro-QoL Lower Extremity Function Long Form
Short Name:
NeuroQoLLwrExtrmtyFnctnLF
Description:
NeuroQoL Lower Extremity Function.Copyright 2008-2013 David Cella and the PROMIS Health Organization on behalf of the National Institute for Neurological Disorders and Stroke (NINDS)
Disease:
Traumatic Brain Injury , General (For all diseases)
Organization:
FITBIR
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-12-28
Owner:
Number of Data Elements:
40
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 (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

Lower Extremity Function LF (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Quality of Life - Movement sit stand toilet seat scale  The scale which represents the extent to which the participant was able to get on and off the toilet, as part of Neuro-QOL Lower Extremity Function. QoLMoveSitStndToiletSeatScl Recommended CDE
2 Quality of Life - Movement up down step curb ability scale  The scale which represents the extent to which the participant was able to step up and down curbs, as part of Neuro-QOL Lower Extremity Function. QolMoveUpDownStepCurbAbltyScl Recommended CDE
3 Quality of Life - Movement in out car ability scale  The scale which represents the extent to which the participant was able to get in and out of the car, as part of Neuro-QOL Lower Extremity Function. QolMoveInOutCarAbilityScl Recommended CDE
4 Quality of Life - Movement bed chair ability scale  The scale which represents the extent to which the participant was able to get out of bed into a chair, as part of Neuro-QOL Lower Extremity Function. QolMoveBedChairAbilityScl Recommended CDE
5 Quality of Life - Movement push open heavy door ability scale  The scale which represents the extent to which the participant was able to push open a heavy door, as part of Neuro-QOL Lower Extremity Function. QolMovePshOpnHvyDoorAblityScl Recommended CDE
6 Quality of Life - Movement errand shop ability scale  The scale which represents the extent to which the participant was able to run errands and shop, as part of Neuro-QOL Lower Extremity Function. QolMoveErrandShopAbilityScl Recommended CDE
7 Quality of Life - Movement without assistance floor stand ability scale  The scale which represents the extent to which the participant was able to get up off the floor from lying on their back without help, as part of Neuro-QOL Lower Extremity Function. QolMoveWthoutAsstnFlrAbltyScl Recommended CDE
8 Quality of Life - Movement walk fifteen minute duration ability scale  The scale which represents the extent to which the participant was able to go for a walk of at least 15 minutes, as part of Neuro-QOL Lower Extremity Function. QolMoveWlkFftnMinDurAbltyScl Recommended CDE
9 Quality of Life - Movement armless straight chair stand up difficulty scale  The scale which represents the amount of difficulty the participant currently has in standing up from an armless straight chair (e.g., dining room chair), as part of Neuro-QOL Lower Extremity Function. QoLMoveArmlssStrghtChrAbltyScl Recommended CDE
10 Quality of Life - Movement chair sit stand difficulty scale  The scale which represents the amount of difficulty the participant currently has in sitting down on and standing up from a chair with arms, as part of Neuro-QOL Lower Extremity Function. QolMoveChrSitStndDifAbltyScl Recommended CDE
11 Quality of Life - Movement bed sit lay down difficulty scale  The scale which represents the amount of difficulty the participant currently has in moving from sitting at the side of the bed to lying down on their back, as part of Neuro-QOL Lower Extremity Function. QolMoveBedSitLayDownDiffScl Recommended CDE
12 Quality of Life - Movement low soft couch stand difficulty scale  The scale which represents the amount of difficulty the participant currently has in standing up from a low, soft couch, as part of Neuro-QOL Lower Extremity Function. QoLMoveLowSoftCouchStndDiffScl Recommended CDE
13 Quality of Life - Movement flight stair handrail up down difficulty scale  The scale which represents the amount of difficulty the participant currently has in going up and down a flight of stairs inside, using a handrail, as part of Neuro-QOL Lower Extremity Function. QolMoveFlghtStrUpDwnDiffScl Recommended CDE
14 Quality of Life - Movement uneven surface walk difficulty scale  The scale which represents the amount of difficulty the participant currently has in walking on uneven surfaces (e.g., grass, dirt road or sidewalk), as part of Neuro-QOL Lower Extremity Function. QolMoveUnevenSrfaceWlkDiffScl Recommended CDE
15 Quality of Life - Movement single floor walk difficulty scale  The scale which represents the amount of difficulty the participant currently has in walking around one floor of their home, as part of Neuro-QOL Lower Extremity Function. QolMoveSingleFloorWalkDiffScl Recommended CDE
16 Quality of Life - Movement twenty minute duration brisk walk difficulty scale  The scale which represents the amount of difficulty the participant currently has in taking a 20-minute brisk walk, without stopping to rest, as part of Neuro-QOL Lower Extremity Function. QoLMoveTwtyMnDrtnBrskWkDiffScl Recommended CDE
17 Quality of Life - Movement outdoor slippery surface walk difficulty scale  The scale which represents the amount of difficulty the participant currently has in walking on a slippery surface, outdoors, as part of Neuro-QOL Lower Extremity Function. QoLMoveOutdrSlprySrfcWkDiffScl Recommended CDE
18 Quality of Life - Movement no handrail stair climb difficulty scale  The scale which represents the amount of difficulty the participant currently has in climbing stairs step over step without a handrail (alternating feet), as part of Neuro-QOL Lower Extremity Function. QoLMoveNoHandrlStrClmbDiffScl Recommended CDE
19 Quality of Life - Movement dark room no fall walk difficulty scale  The scale which represents the amount of difficulty the participant currently has in walking in a dark room without falling, as part of Neuro-QOL Lower Extremity Function. QoLMoveDrkRmNoFallWalkDiffScl Recommended CDE

NeuroQoL Form Administration (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Quality of Life in Neurological Disorders (Neuro-Qol) - Form administered status  The specific Neuro-Qol form administered status, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). QoLFormStatus Recommended CDE

NeuroQol Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Quality of Life in Neurological Disorders (Neuro-Qol) - Items completed count  The count of items on the Neuro-Qol form completed by the participant, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). QoLItemCompletedCount Recommended CDE
2 Quality of Life in Neurological Disorders (Neuro-Qol) - Raw score  The participant's raw score on the Neuro-Qol form, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). QoLRawScore Recommended CDE
3 Quality of Life in Neurological Disorders (Neuro-Qol) - Standard error  Standard error, as part of the Quality of Life in Neurological Disorders (Neuro-Qol) QoLStandardError Recommended CDE
4 Quality of Life in Neurological Disorders (Neuro-Qol) - T-score value  The value of the T-score, a standardized score with a mean of 50 and a standard deviation (SD) of 10 representing the rescaled raw score, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).(PROMIS). QoLTScore Recommended CDE
5 Quality of Life in Neurological Disorders (Neuro-Qol) - Theta value  Theta metric value reported from the CAT Neuro-Qol results, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). QoLThetaVal Recommended CDE

 Change History

 Administrative Change History