CDE Detailed Report

Disease: Multiple Sclerosis
Sub-Domain: General Health History
CRF: Behavioral History

Displaying 1 - 22 of 22
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
C00714 Behavioral history assessment date and time BehavrlHistAssmtDateTime Date (and time, if applicable and known) the participant/subject behavioral history was taken. Date (and time, if applicable and known) the participant/subject behavioral history was taken. Date behavioral history taken Date or Date & Time

Record the date (and time) the behavioral history was taken. 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.).

No references available Adult;Pediatric Supplemental 3.00 2013-07-18 14:26:06.9 Behavioral History General Health History Participant History and Family History

Free-Form Entry

3170040
C00704 Alcohol drinking day average drinks consumed range AlcDrinkingDayAvgDrinks The counted number of drinks containing alcohol consumed by the participant/subject on a typical day when he/she is drinking. It is noted that the meaning of "drinks consumed" differs from one nation and culture to another, so the most common alcoholic beverages likely to be consumed will be defined as well as quantity of each that constitutes a drink (approximately 10 grams of pure ethanol). For example, one bottle of beer (330 ml at 5% ethanol), a glass of wine (140 ml at 12% ethanol), and a shot of spirits (40 ml at 40% ethanol) represent a standard drink of about 13 g of ethanol. The counted number of drinks containing alcohol consumed by the participant/subject on a typical day when he/she is drinking. It is noted that the meaning of "drinks consumed" differs from one nation and culture to another. How many alcoholic drinks do you have on a typical day when you are drinking 1 or 2;3 or 4;5 or 6;7, 8, or 9;10 or more;Unknown 1 or 2;3 or 4;5 or 6;7, 8, or 9;10 or more;Unknown Alphanumeric

Choose one. Response is obtained from participant/ subject, family member, friend, or chart/ medical record. Unknown includes the scenario where information is not documented in the medical record.

Question is from the Alcohol Use Disorders Identification Test (AUDIT) - http://www.who.int/substance_abuse/activities/sbi/en/ Adult;Pediatric Supplemental 3.00 2013-07-18 16:35:19.49 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3171647
C00718 Tobacco use duration TobcoUseDur Duration in years participant/subject has used tobacco products (e.g. cigarettes, cigars, chewing tobacco or pipe) Duration in years participant/subject has used tobacco products (e.g. cigarettes, cigars, chewing tobacco or pipe) Duration in years participant/subject has used tobacco products (e.g. cigarettes, cigars, chewing tobacco or pipe) Numeric Values

Exclude any periods when the participant/subject quit using tobacco. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document when the behavioral history was collected so as to determine whether this information was obtained prior to study enrollment or later. Substance abuse directly before injury may have contributed to the incident causing injury. In general, substance abuse may indicate increased risk taking behavior.

Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. Biering-SØrensen F, Krassioukov A, Alexander MS, Donovan W, Karlsson AK, Mueller G, Perkash I, William Sheel A, Wecht J, Schilero GJ.International Spinal Cord Injury Pulmonary Function Basic Data Set. Spinal Cord. 2012 Jun; 50(6):418-21. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Behavioral History General Health History Participant History and Family History

Free-Form Entry

0 99 year
C00705 Alcohol current use indicator AlcCurntUseInd Indicator of whether the participant/subject consumed at least one alcoholic drink within the past 12 months Indicator of whether the participant/subject consumed at least one alcoholic drink within the past 12 months Current drinker? Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one. Response is obtained from participant/ subject, family member, friend, or chart/ medical record. Unknown includes the scenario where information is not documented in the medical record. A current drinker is defined as consuming at least one drink within the past year. For MS: If "Yes" is answered, skip to question 3 History can be obtained from participant/ subject, family member, friend, or chart/ medical record. In the U.S., a single drink serving contains about 14 grams of ethanol or "pure" alcohol. Although the drinks below are different sizes, each one contains the same amount of pure alcohol and counts as a single drink: 12 oz. of beer (about %% alcohol) = 8-9 oz. of malt liquor (about 7% alcohol) = 5 oz. of wine (about 12% alcohol) = 1.5 oz. of hard liquor (about 40% alcohol)

No references available Adult;Pediatric Supplemental 3.00 2013-07-18 14:26:06.9 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3171540
C00719 Tobacco product used type TobcoProdctUsedTyp Type of tobacco product (e.g., cigarettes, cigars, chewing tobacco or pipe) used by the participant/subject Type of tobacco product (e.g., cigarettes, cigars, chewing tobacco or pipe) used by the participant/subject Type(s) of tobacco used Filtered cigarettes;Non-filtered cigarettes;Low tar cigarettes;Cigars;Pipes;Chewing tobacco;Other, specify Filtered cigarettes;Non-filtered cigarettes;Low tar cigarettes;Cigars;Pipes;Chewing tobacco;Other, specify Alphanumeric

Choose all that apply. Response is obtained from participant/subject, family member, friend, or chart/medical record as soon as possible after visit/admission. For TBI: Document whether this information was obtained prior to study enrollment or later.

Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Behavioral History General Health History Participant History and Family History

Multiple Pre-Defined Values Selected

3179449v1
C00706 Alcohol prior use indicator AlcPriorUseInd Indicator of the participant's/subject's alcohol consumption prior to the past 12 months Indicator of the participant's/subject's alcohol consumption prior to the past 12 months Past drinker Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one. Document when the behavioral history was collected so as to determine whether this information was obtained prior to study enrollment or later. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Substance abuse directly before injury may have contributed to the incident causing injury. In general, substance abuse may indicate increased risk taking behavior. For MS: If "No" is answered, skip to Drug section

Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3171578
C00730 Alcohol use frequency AlcUseFreq The frequency of consumption of alcohol by the participant. The frequency of consumption of alcohol by the participant. How often do you have a drink containing alcohol? Monthly or less;2 to 4 times a month;2 to 3 times a week;4 or more times a week;Unknown Monthly or less;2 to 4 times a month;2 to 3 times a week;4 or more times a week;Unknown Alphanumeric

Choose one. If "Never" is answered, skip to "Have you ever been hospitalized for an alcohol related problem". In some cases, response is obtained from participant/ subject, family member, friend, or chart/ medical record. Unknown includes the scenario where information is not documented in the medical record.

Question is from the Alcohol Use Disorders Identification Test (AUDIT) - http://www.who.int/substance_abuse/activities/sbi/en/ Adult;Pediatric Supplemental 3.00 2013-07-18 16:35:19.49 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3171627
C00707 Alcohol consume six or more drinks frequency AlcConsume6MoreDrinkFreq The rate of occurrence for when the participant/subject consumes six or more drinks containing alcohol on one occasion. It is noted that the meaning of "drinks consumed" differs from one nation and culture to another, so the most common alcoholic beverages likely to be consumed will be defined as well as quantity of each that constitutes a drink (approximately 10 grams of pure ethanol). For example, one bottle of beer (330 ml at 5% ethanol), a glass of wine (140 ml at 12% ethanol), and a shot of spirits (40 ml at 40% ethanol) represent a standard drink of about 13 g of ethanol. The rate of occurrence for when the participant/subject consumes six or more drinks containing alcohol on one occasion. It is noted that the meaning of "drinks consumed" differs from one nation and culture to another. How often do you have six or more drinks on one occasion? Never;Less than monthly;Monthly;Weekly;Daily or almost daily;Unknown Never;Less than monthly;Monthly;Weekly;Daily or almost daily;Unknown Alphanumeric

Choose one. Response is obtained from participant/ subject, family member, friend, or chart/ medical record. Unknown includes the scenario where information is not documented in the medical record. Current Guidelines for MS is incorrect: Choose one if currently drinks

Question is from the Alcohol Use Disorders Identification Test (AUDIT) - http://www.who.int/substance_abuse/activities/sbi/en/ Adult;Pediatric Supplemental 3.00 2013-07-18 16:35:19.49 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3171659
C16160 Tobacco smoked 100 cigarettes indicator Tobco100CigarettesInd Indicator for whether participant/subject has smoked at least 100 cigarettes in entire life. Indicator for whether participant/subject has smoked at least 100 cigarettes in entire life. Have you smoked at least 100 cigarettes in your entire life? Yes;No;Unknown Yes;No;Unknown Alphanumeric

If "No" is answered, skip to question 9.

No references available Adult;Pediatric Supplemental 3.00 2013-06-11 00:00:00.0 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

C00708 Alcohol use related to hospitalization indicator AlcUseRelatedHospInd Indicator of whether the participant/subject has been hospitalized for an alcohol-related problem (i.e., esophageal varices, delirium tremens (DTs), cirrhosis and others) Indicator of whether the participant/subject has been hospitalized for an alcohol-related problem (i.e., esophageal varices, delirium tremens (DTs), cirrhosis and others) Have you ever been hospitalized for an alcohol-related problem Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one. Response is obtained from participant/ subject, family member, friend, or chart/ medical record. Unknown includes the scenario where information is not documented in the medical record.

No references available Adult;Pediatric Supplemental 3.00 2013-07-18 14:26:06.9 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3171677
C16162 Tobacco days smoked in past 30 days count TobcoDaysSmokedPast30DaysCt Number of days during PAST 30 DAYS that participant/subject smoked a cigarette. Number of days during PAST 30 DAYS that participant/subject smoked a cigarette. On how many of the PAST 30 DAYS did you smoke a cigarette? Numeric Values

Record number of days a cigarette was smoked in the past 30 days.

No references available Adult;Pediatric Supplemental 3.00 2013-06-11 00:00:00.0 Behavioral History General Health History Participant History and Family History

Free-Form Entry

day
C00709 Tobacco cigarettes smoked daily average number TobcoCigaretSmokedDlyAvgNum Average number of cigarettes the participant/subject smokes daily (On the days you smoked cigarettes during the past 30 days, how many cigarettes did you smoke per day, on average?) Average number of cigarettes the participant/subject smokes daily (On the days you smoked cigarettes during the past 30 days, how many cigarettes did you smoke per day, on average?) Average number of cigarettes smoked per day Less than one cigarette per day;1 cigarette per day;2 to 5 cigarettes per day;6 to 15 cigarettes per day (about 1/2 pack);16 to 25 cigarettes per day (about 1 pack);26 to 35 cigarettes per day (about 1 1/2 packs);More than 35 cigarettes per day (about 2 packs or more);Unknown Less than one cigarette per day;1 cigarette per day;2 to 5 cigarettes per day;6 to 15 cigarettes per day (about ½ pack);16 to 25 cigarettes per day (about 1 pack);26 to 35 cigarettes per day (about 1 ½ packs);More than 35 cigarettes per day (about 2 packs or more);Unknown Alphanumeric

Record average number of cigarettes currently smoked a day. Only answer if former or current smoker. Choose one. Response is obtained from participant/ subject, family member, friend, or chart/ medical record.

PhenX Toolkit: https://www.phenxtoolkit.org/index.php - Protocol 1: Tobacco - 30-Day Quantity and Frequency (Adolescent Protocol) #030801 For SCI: Biering-SØrensen F, Krassioukov A, Alexander MS, Donovan W, Karlsson AK, Mueller G, Perkash I, William Sheel A, Wecht J, Schilero GJ.International Spinal Cord Injury Pulmonary Function Basic Data Set. Spinal Cord. 2012 Jun; 50(6):418-21. Adult;Pediatric Supplemental 3.00 2013-07-18 14:26:06.9 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3170853
C18670 Subscribed drug or substance illicitly used other text SbscrbdDrgSubIllctUseOTH The free-text field related to 'Drug or substance illicitly used category' specifying other text. Category of illegal drugs, prescription, or over-the-counter drugs the participant/subject used for purposes other than those for which they are meant to be used, or in large amounts Drug or substance illicitly used category' specifying other text. Category of illegal drugs, prescription, or over-the-counter drugs the participant/subject used for purposes other than those for which they are meant to be used, or in large amounts Other, specify Alphanumeric

If currently uses illicit drugs/substances, choose all that apply. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document whether this information was obtained prior to study enrollment or later. Do not record medications that are prescribed for medical purposes. Collect information on substances and medications taken for reasons other than prescription, or taken more frequently or at higher doses than prescribed. Assure participant/subject that information on such use will be treated as strictly confidential. For each drug class, list specific drug(s) used. Include drugs used at any time in life, but do not include drugs prescribed by doctor.

Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. PhenX Toolkit - Substances - Lifetime Use Protocol 031100: https://www.phenxtoolkit.org/index.php Adult;Pediatric Supplemental 1.00 2014-05-27 13:34:46.0 Behavioral History General Health History Participant History and Family History 4000

Free-Form Entry

3171797
C00710 Tobacco current use indicator TobcoUseCurntInd Indicator for whether the participant/subject regularly uses tobacco products (e.g., cigarettes, cigars, chewing tobacco or pipe) at the present time. Indicator for whether the participant/subject regularly uses tobacco products (e.g., cigarettes, cigars, chewing tobacco or pipe) at the present time. Current tobacco use? Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one. Response is obtained from participant/ subject, family member, friend, or chart/ medical record. For TBI: Add date stamp for when assessed.Recommend collection at least on date of TBI.

TBI reference: Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3170060
C18770 Tobacco product used other text TobcoProdctUsedOTH The free-text field related to 'Tobacco product used type' specifying other text. Type of tobacco product (e.g. cigarettes, cigars, chewing tobacco or pipe) used by the participant/subject The free-text field related to 'Tobacco product used type' specifying other text. Type of tobacco product (e.g. cigarettes, cigars, chewing tobacco or pipe) used by the participant/subject Other, specify Alphanumeric

Choose all that apply. Response is obtained from participant/subject, family member, friend, or chart/medical record as soon as possible after visit/admission. For TBI: Document whether this information was obtained prior to study enrollment or later.

Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. Adult;Pediatric Supplemental 1.00 2014-05-27 13:34:46.0 Behavioral History General Health History Participant History and Family History 4000

Free-Form Entry

3170860
C00700 Alcohol use stopped age value AlcUseStopAgeVal Age in years when participant/subject stopped ingesting alcoholic beverages, including social drinking Age in years when participant/subject stopped ingesting alcoholic beverages, including social drinking Age quit drinking Numeric Values

History can be obtained from participant/ subject, family member, friend, or chart/ medical record. The age in years should be collected or N/A (Not applicable if subject never smoked) should be selected.

No references available Adult;Pediatric Supplemental 3.00 2013-07-18 14:26:06.9 Behavioral History General Health History Participant History and Family History

Free-Form Entry

0 120 year 2008448
C00711 Tobacco prior use indicator TobcoPriorUseInd Indicator of the participant's/subject's past regular tobacco (e.g., cigarettes, cigars, chewing tobacco or pipe) use prior to the past 12 months Indicator of the participant's/subject's past regular tobacco (e.g., cigarettes, cigars, chewing tobacco or pipe) use prior to the past 12 months Past tobacco use? Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one. Response is obtained from participant/ subject, family member, friend, or chart/ medical record. For TBI: Choose one. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document when the behavioral history was collected so as to determine whether this information was obtained prior to study enrollment or later. Substance abuse directly before injury may have contributed to the incident causing injury. In general, substance abuse may indicate increased risk taking behavior.

For TBI: Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3170080
C00701 Tobacco use stopped age value TobcoUseStopAgeVal Age in years when participant/subject stopped using tobacco products (e.g., cigarettes, cigars, chewing tobacco or pipe) Age in years when participant/subject stopped using tobacco products (e.g., cigarettes, cigars, chewing tobacco or pipe) Age stopped tobacco use Numeric Values

History can be obtained from participant/ subject, family member, friend, or chart/ medical record. The age in years should be collected or N/A (Not applicable if subject never smoked) should be selected.

No references available Adult;Pediatric Supplemental 3.00 2013-07-18 14:26:06.9 Behavioral History General Health History Participant History and Family History

Free-Form Entry

0 120 year 2524471
C00712 Subscribed drug or substance illicitly used category SbscrbdDrgSubIllctUseCat Category of illegal drugs, prescription, or over-the-counter drugs subscribed by the participant/subject, and used for purposes other than those for which they are meant to be used, or in large amounts Category of illegal drugs, prescription, or over-the-counter drugs subscribed by the participant/subject, and used for purposes other than those for which they are meant to be used, or in large amounts If YES, specify illicit drug type(s) used Sedatives (e.g., sleeping pills, barbiturates, Seconal, Quaaludes, or Chloral Hydrate);Tranquilizers or anti-anxiety drugs (e.g., Valium, Librium, muscle relaxants, or Zanax);Painkillers (e.g., Codeine, Darvon, Percodan, Dilaudid, or Demerol);Stimulants (e.g., Preludin, Benzedrine, Methadrine, uppers, or speed);Marijuana, hash, THC, or grass;Cocaine or crack;Hallucinogens (e.g., Ecstasy, LSD, mescaline, psilocybin, PCP, angel dust, or peyote);Inhalants or Solvents (e.g., amyl nitrate, nitrous oxide, glue, toluene, or gasoline;Heroin;Other, specify (e.g., Methadone, Elavil, steroids, Thorazine, or Haldol) Sedatives (e.g., sleeping pills, barbiturates, Seconal, Quaaludes, or Chloral Hydrate);Tranquilizers or anti-anxiety drugs (e.g., Valium, Librium, muscle relaxants, or Zanax);Painkillers (e.g., Codeine, Darvon, Percodan, Dilaudid, or Demerol);Stimulants (e.g., Preludin, Benzedrine, Methadrine, uppers, or speed);Marijuana, hash, THC, or grass;Cocaine or crack;Hallucinogens (e.g., Ecstasy, LSD, mescaline, psilocybin, PCP, angel dust, or peyote);Inhalants or Solvents (e.g., amyl nitrate, nitrous oxide, glue, toluene, or gasoline;Heroin;Other, specify (e.g., Methadone, Elavil, steroids, Thorazine, or Haldol) Alphanumeric

If currently uses illicit drugs/substances, choose all that apply. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document whether this information was obtained prior to study enrollment or later. Do not record medications that are prescribed for medical purposes. Collect information on substances and medications taken for reasons other than prescription, or taken more frequently or at higher doses than prescribed. Assure participant/subject that information on such use will be treated as strictly confidential. For each drug class, list specific drug(s) used. Include drugs used at any time in life, but do not include drugs prescribed by doctor.

Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. PhenX Toolkit - Substances - Lifetime Use Protocol 031100: https://www.phenxtoolkit.org/index.php Adult;Pediatric Supplemental 3.00 2013-07-22 09:34:41.527 Behavioral History General Health History Participant History and Family History

Multiple Pre-Defined Values Selected

3171797
C00702 Alcohol use started age value AlcUseStrtAgeVal Age in years when participant/subject started ingesting alcoholic beverages, including social drinking Age in years when participant/subject started ingesting alcoholic beverages, including social drinking Age started drinking Numeric Values

History can be obtained from participant/ subject, family member, friend, or chart/ medical record.

No references available Adult;Pediatric Supplemental 3.00 2013-07-18 14:26:06.9 Behavioral History General Health History Participant History and Family History

Free-Form Entry

0 120 year 2008447
C00713 Drug or substance current illicit use indicator DrgSubstCurrntIllicitUseInd Indicator of participant's/subject's use of illegal drugs, prescription or over-the-counter drugs in the past year for purposes other than those for which they are meant to be used, or in large amounts Indicator of participant's/subject's use of illegal drugs, prescription or over-the-counter drugs in the past year for purposes other than those for which they are meant to be used, or in large amounts Current drug user Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one. A current drug user is defined as using any illicit drug within the past year. For TBI: Choose one. Response is obtained by report of the participant/subject or proxy as soon as possible after visit/admission. Document when the behavioral history was collected so as to determine whether this information was obtained prior to study enrollment or later. Do not record medications that are prescribed for medical purposes (these should be entered in the element 'medical history'.) Collect information on substances and medications taken for reasons other than prescription, or taken more frequently or at higher doses than prescribed. Assure participant/subject that information on such use will be treated as strictly confidential. Recommend collection as soon as possible after visit/admission. Substance abuse directly before injury may have contributed to the incident causing injury. In general, substance abuse may indicate increased risk taking behavior.

Corrigan JD, Bogner J, Holloman C. Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Inj. 2012;26(2):139-50. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Behavioral History General Health History Participant History and Family History

Single Pre-Defined Value Selected

3171724
C00703 Tobacco use started age value TobcoUseStrtAgeVal Age in years when participant/subject started using tobacco products (e.g., cigarettes, cigars, chewing tobacco or pipe) Age in years when participant/subject started using tobacco products (e.g., cigarettes, cigars, chewing tobacco or pipe) Age started tobacco use Numeric Values

History can be obtained from participant/ subject, family member, friend, or chart/ medical record.

No references available Adult;Pediatric Supplemental 3.00 2013-07-18 14:26:06.9 Behavioral History General Health History Participant History and Family History

Free-Form Entry

0 120 year 2178045
CSV