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CDE Detailed Report
This report contains detailed information about the selected CDEs.
Note: If at least one CDE was selected from a copyright- or trademark-protected instrument/scale then all of the CDEs from that instrument/scale are included in this report.
Disease: Mitochondrial Disease
Sub-Domain: General Health History
CRF: Dietary Supplements
Item count: 8 (8 distinct CDEs)
CDE ID
CDE Name
Variable Name
Definition / Description
Question Text
Permissible Value
Description
Data Type
Instructions
References
Population
Classification (e.g., Core)
Version #
Version Date
Aliases for Variable Name
CRF Module / Guideline
© or TM
Sub-Domain
Domain
Previous Title
Size
Input Restrictions
Min Value
Max Value
Measurement Type
LOINC ID
SNOMED
caDSR ID
CDISC ID
C19714
Dietary supplement study use indicator
DietrSupplStdyUseInd
Indicator to whether the participant/subject took dietary supplements before or during the study.
Did the participant/subject take any dietary supplements before or during the study?
Yes;No;
Yes;No;
Alphanumeric
Choose one. If this question is answered YES then at least one prior/concomitant dietary supplement record needs to be recorded. Do NOT record study dietary supplements taken (if study has a dietary supplement intervention) on this form.
No references available
Adult;Pediatric
Supplemental
1.0
2/2/2015
Aliases for variable name not defined
Dietary Supplements
General Health History
Participant History and Family History
  
Single Pre-Defined Value Selected
       
C19715
Dietary supplement generic name
DietrSupplGenrNam
Generic name for the supplement taken.
Dietary Supplement Generic Name
Biotin;Folic Acid;Folinic acid;Vitamin B1 (thiamin);Vitamin B2 (riboflavin);Vitamin B3 (niacin);Vitamin B6 (pyridoxine);Vitamin C (ascorbic acid);Vitamin D2 (ergocalciferol);Vitamin D3 (cholecalciferol);Calcium;Magnesium;Phosphorous;Selenium;Arginine;Carnitine;Citrate;Citrulline;Coenzyme Q10;Creatinine;Lipoic acid (thioctic acid);N-acetyl cysteine;Succinate;Uridine;Other;
Biotin;Folic Acid;Folinic acid;Vitamin B1 (thiamin);Vitamin B2 (riboflavin);Vitamin B3 (niacin);Vitamin B6 (pyridoxine);Vitamin C (ascorbic acid);Vitamin D2 (ergocalciferol);Vitamin D3 (cholecalciferol);Calcium;Magnesium;Phosphorous;Selenium;Arginine;Carnitine;Citrate;Citrulline;Coenzyme Q10;Creatinine;Lipoic acid (thioctic acid);N-acetyl cysteine;Succinate;Uridine;Other;
Alphanumeric
Record the verbatim name (generic or trade name) of the dietary supplement(s) the participant/subject reports taking. Dietary supplements may be taken as a commercial multivitamin or multivitamin/mineral preparation (e.g. a children’s chewable multivitami
No references available
Adult;Pediatric
Supplemental
1.0
2/2/2015
Aliases for variable name not defined
Dietary Supplements
General Health History
Participant History and Family History
  
Multiple Pre-Defined Values Selected
       
C19716
Dietary supplement compounded formulation ingredient text
DietrSupplCompFormlIngTxt
List of ingredients used to make a specially compounded formulation.
Specially Compounded Formulations (list ingredients)
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
1.0
2/2/2015
Aliases for variable name not defined
Dietary Supplements
General Health History
Participant History and Family History
 
255
Free-Form Entry
       
C19717
Dietary supplement brand formulation name
DietrSupplBrandFormNam
Name of the brand or formulation subject took.
Brand/formulation
  
Alphanumeric
Record the brand name and chemical form. For example, for calcium, indicate if it is calcium carbonate, calcium citrate, etc. For coenzyme Q10, note if it is ubiquinol, ubiquinone, idebenone, MitoQ, etc.
No references available
Adult;Pediatric
Supplemental
1.0
2/2/2015
Aliases for variable name not defined
Dietary Supplements
General Health History
Participant History and Family History
 
255
Free-Form Entry
       
C19718
Dietary supplement indication reason
DietrSupplIndicatnRsn
Reason the participant is taking the drug.
Indication
  
Alphanumeric
Record the reason the participant/subject gives for taking the dietary supplement.
No references available
Adult;Pediatric
Supplemental
1.0
2/2/2015
Aliases for variable name not defined
Dietary Supplements
General Health History
Participant History and Family History
 
255
Free-Form Entry
       
C19719
Dietary supplement dose value
DietrSupplDoseVal
Strength of the dietary supplement the participant/subject is taking.
Dose
  
Numeric Values
Record the strength and units of the dietary supplement the participant/subject is taking.
No references available
Adult;Pediatric
Supplemental
1.0
2/2/2015
Aliases for variable name not defined
Dietary Supplements
General Health History
Participant History and Family History
  
Free-Form Entry
       
C19720
Dietary supplement administered count
DietrSupplAdminCt
Numerical number of how many times the supplement was taken.
Frequency
  
Numeric Values
Record how often the medication is being taken.
No references available
Adult;Pediatric
Supplemental
1.0
2/2/2015
Aliases for variable name not defined
Dietary Supplements
General Health History
Participant History and Family History
  
Free-Form Entry
       
C19721
Dietary supplement route administered anatomic site
DietrSupplRouteAdminAnatSite
Anatomic site for supplement entry being administered.
Route
Buccal;Inhaled;Intramuscular;Intravenous / Parenteral;Nasal;By mouth;Enteral (via tube);Subcutaneous;Sublingual;Transdermal;Unknown;Other, specify;
Buccal;Inhaled;Intramuscular;Intravenous / Parenteral;Nasal;By mouth;Enteral (via tube);Subcutaneous;Sublingual;Transdermal;Unknown;Other, specify;
Alphanumeric
Select from the following for dietary supplement route of administration:
No references available
Adult;Pediatric
Supplemental
1.0
2/2/2015
Aliases for variable name not defined
Dietary Supplements
General Health History
Participant History and Family History
  
Multiple Pre-Defined Values Selected
       
07-15-2019
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