CDE Detailed Report

Disease: Amyotrophic Lateral Sclerosis
Sub-Domain: Functional Outcomes
CRF: Edmonton Symptom Assessment System (ESAS)

Displaying 1 - 14 of 14
CDE ID CDE Name Variable Name Definition Short Description Additional Notes (Question Text) Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C11663 Edmonton Symptom Assessment System (ESAS) - breath shortness scale ESASBreathShortnessScale Scale rating the intensity of shortness of breath, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating the intensity of shortness of breath, as part of the Edmonton Symptom Assessment System (ESAS) Shortness of breath 0;1;2;3;4;5;6;7;8;9;10 No shortness of breath;;;;;;;;;;Worst possible shortness of breath Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C11664 Edmonton Symptom Assessment System (ESAS) - other problems scale ESASOtherProblemScale Scale rating the intensity of other problems, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating the intensity of other problems, as part of the Edmonton Symptom Assessment System (ESAS) Other problem 0;1;2;3;4;5;6;7;8;9;10 Best or not present;1;2;3;4;5;6;7;8;9;Worst Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C11665 Edmonton Symptom Assessment System (ESAS) - anatomic site ESASAnatomicSite Anatomic sites that hurt to be marked on diagrams of the front and the back of the body, as part of the Edmonton Symptom Assessment System (ESAS) Anatomic sites that hurt to be marked on diagrams of the front and the back of the body, as part of the Edmonton Symptom Assessment System (ESAS) Please mark on these pictures where it is you hurt Alphanumeric

Refer to picture on form

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points 255

Free-Form Entry

C11655 Edmonton Symptom Assessment System (ESAS) - pain scale ESASPainScale Scale rating the intensity of pain, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating the intensity of pain, as part of the Edmonton Symptom Assessment System (ESAS) Pain 0;1;2;3;4;5;6;7;8;9;10 No Pain;;;;;;;;;;Worst possible pain Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C17777 Edmonton Symptom Assessment System (ESAS) - form complete date and time ESASFormCompleteDateTime Date and time the assessment was done, as part of the Edmonton Symptom Assessment System (ESAS) Date the assessment was done, as part of the Edmonton Symptom Assessment System (ESAS) Date Time Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Free-Form Entry

C11656 Edmonton Symptom Assessment System (ESAS) - tiredness scale ESASTirednessScale Scale rating the intensity of tiredness, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating the intensity of tiredness, as part of the Edmonton Symptom Assessment System (ESAS) Tiredness 0;1;2;3;4;5;6;7;8;9;10 Not tired;;;;;;;;;;Worst possible tiredness Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C17779 Edmonton Symptom Assessment System (ESAS) - patient name ESASPatientName Name of patient taking the assessment. Edmonton Symptom Assessment System (ESAS) Name of patient taking the assessment. Edmonton Symptom Assessment System (ESAS) Patient's name Alphanumeric Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points 255

Free-Form Entry

C11657 Edmonton Symptom Assessment System (ESAS) - nausea scale ESASNauseaScale Scale rating the intensity of nausea, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating the intensity of nausea, as part of the Edmonton Symptom Assessment System (ESAS) Nausea 0;1;2;3;4;5;6;7;8;9;10 Not nauseated;;;;;;;;;;Worst possible nausea Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C17780 Edmonton Symptom Assessment System (ESAS) - person completing form occupation name ESASPrsnComplFrmOccupatnName Name of occupation of the person completing the form, as part of the Edmonton Symptom Assessment System (ESAS) Name of occupation of the person completing the form, as part of the Edmonton Symptom Assessment System (ESAS) Complete by Alphanumeric Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points 255

Free-Form Entry

C11658 Edmonton Symptom Assessment System (ESAS) - depression scale ESASDepressionScale Scale rating the intensity of depression, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating the intensity of depression, as part of the Edmonton Symptom Assessment System (ESAS) Depression 0;1;2;3;4;5;6;7;8;9;10 Not depressed;;;;;;;;;;Worst possible depression Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C11659 Edmonton Symptom Assessment System (ESAS) - anxiety scale ESASAnxietyScale Scale rating the intensity of anxiety, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating the intensity of anxiety, as part of the Edmonton Symptom Assessment System (ESAS) Anxiety 0;1;2;3;4;5;6;7;8;9;10 Not anxious;;;;;;;;;;Worst possible anxiety Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C11660 Edmonton Symptom Assessment System (ESAS) - drowsiness scale ESASDrowsinessScale Scale rating the intensity of drowsiness, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating the intensity of drowsiness, as part of the Edmonton Symptom Assessment System (ESAS) Drowsiness 0;1;2;3;4;5;6;7;8;9;10 Not drowsy;;;;;;;;;;Worst possible drowsiness Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C11661 Edmonton Symptom Assessment System (ESAS) - appetite scale ESASAppetiteScale Scale rating appetite, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating appetite, as part of the Edmonton Symptom Assessment System (ESAS) Appetite 0;1;2;3;4;5;6;7;8;9;10 Best appetite;;;;;;;;;;Worst possible appetite Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C11662 Edmonton Symptom Assessment System (ESAS) - wellbeing scale ESASWellbeingScale Scale rating wellbeing, as part of the Edmonton Symptom Assessment System (ESAS) Scale rating wellbeing, as part of the Edmonton Symptom Assessment System (ESAS) Feeling of wellbeing 0;1;2;3;4;5;6;7;8;9;10 Best feeling of wellbeing;;;;;;;;;;Worst possible feeling of wellbeing Numeric Values

Please circle the number that best describes:

Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J. Palliat Care 1991; 7(2):6-9. Adult Supplemental 3.00 2013-07-22 16:57:17.79 Edmonton Symptom Assessment System (ESAS) Functional Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

CSV