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

 General Details

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

 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 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 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Headaches scale  Scale that rates the severity of how the subject now suffers from headaches as compared with before the accident. RPQHeadachesScale Recommended CDE
2 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Dizziness scale  Scale that rates the severity of how the subject now suffers from dizziness as compared with before the accident. RPQDizzinessScale Recommended CDE
3 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Nausea scale  Scale that rates the severity of how the subject now suffers from nausea and/or vomiting as compared with before the accident. RPQNauseaScale Recommended CDE
4 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Noise sensitivity scale  Scale that rates the severity of how the subject now suffers from noise sensitivity and easily upset by loud noise as compared with before the accident. RPQNoiseSensScale Recommended CDE
5 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Sleep disturbance scale  Scale that rates the severity of how the subject now suffers from sleep disturbance as compared with before the accident. RPQSleepDistScale Recommended CDE
6 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Fatigue scale  Scale that rates the severity of how the subject now suffers from fatigue and/or tiring more easily as compared with before the accident. RPQFatigueScale Recommended CDE
7 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Irritable scale  Scale that rates the severity of how the subject now suffers from being irritable, easily angered as compared with before the accident. RPQIrritableScale Recommended CDE
8 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Depression scale  Scale that rates the severity of how the subject now suffers from feeling depressed or tearful as compared with before the accident. RPQDepressedScale Recommended CDE
9 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Frustrated scale  Scale that rates the severity of how the subject now suffers from feeling frustrated or impatient as compared with before the accident. RPQFrustratedScale Recommended CDE
10 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Forgetfulness scale  Scale that rates the severity of how the subject now suffers from forgetfulness/poor memory as compared with before the accident. RPQForgetfulScale Recommended CDE
11 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Poor concentration scale  Scale that rates the severity of how the subject now suffers from poor concentration as compared with before the accident. RPQPoorConcScale Recommended CDE
12 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Longer to think scale  Scale that rates the severity of how the subject now suffers from taking longer to think as compared with before the accident. RPQLongToThinkScale Recommended CDE
13 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Blurred vision scale  Scale that rates the severity of how the subject now suffers from blurred vision as compared with before the accident. RPQBlurredVisionScale Recommended CDE
14 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Light sensitivity scale  Scale that rates the severity of how the subject now suffers from light sensitivity as compared with before the accident. RPQLightSensScale Recommended CDE
15 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Double vision scale  Scale that rates the severity of how the subject now suffers from double vision as compared with before the accident. RPQDblVisionScale Recommended CDE
16 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Restlessness scale  Scale that rates the severity of how the subject now suffers from restlessness as compared with before the accident. RPQRestlessScale Recommended CDE
17 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - First other difficulty scale  Scale that rates the severity of how the subject now suffers from other difficulties as compared with before the accident. Rate the first other difficulty. RPQOthr1DiffcltyScale Recommended CDE
18 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - First other difficulty text  The free-text field related to 'The Rivermead Post-Concussion Symptoms Questionnaire (RPQ)- First other difficulty scale' specifying the first other difficulty text. RPQOthr1DiffcltyTxt Recommended CDE
19 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Second other difficulty scale  Scale that rates the severity of how the subject now suffers from other difficulties as compared with before the accident. Rate the second other difficulty. RPQOthr2DiffcltyScale Recommended CDE
20 The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) - Second other difficulty text  The free-text field related to 'The Rivermead Post-Concussion Symptoms Questionnaire (RPQ)- Second other difficulty scale' specifying the 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

 Change History

 Administrative Change History