CDE Detailed Report
Disease: Sport-Related Concussion
Subdomain Name: Cognitive Assessment
CRF: Acute Concussion Evaluation (ACE)
Displaying 1 - 50 of 59
Subdomain Name: Cognitive Assessment
CRF: Acute Concussion Evaluation (ACE)
Displaying 1 - 50 of 59
| CDE ID | CDE Name | Variable Name | Definition | Short Description | 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 / Guidance) | Subdomain Name | Domain Name | Size | Input Restrictions | Min Value | Max Value | Measurement Type | External Id Loinc | External Id Snomed | External Id caDSR | External Id CDISC |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| C00007 | Birth date | BirthDate | Date (and time, if applicable and known) the participant was born | Date (and time, if applicable and known) the participant was born | DOB: | Date or Date & Time | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 3.1 | 10/16/2024 8:51:14 AM | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
793 | ||||||||||
| C54357 | Acute Concussion Evaluation (ACE) - Symptom check list sleep total count | ACESymptomChkLstSleepTotCt | Total count of sleep symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE) | Total count of sleep symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE | SLEEP Total(0-4) | Numeric Values |
Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
0 | 4 | ||||||||
| C54336 | Acute Concussion Evaluation (ACE) - Impact location anatomic site | ACEImpactLocationAnatSite | Anatomic site of impact injury as related to the Acute Concussion Evaluation (ACE) | Anatomic site of impact injury as related to the Acute Concussion Evaluation (ACE | Location of Impact: | Frontal;Indirect Force;Left Parietal;Left Temporal;Neck;Occipital;Right Parietal;Right Temporal | Frontal;Indirect Force;Left Parietal;Left Temporal;Neck;Occipital;Right Parietal;Right Temporal | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:16:54.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54368 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery headache history prior treatment status | ACERskFcPrtrctRcvHedHxPrRxStat | Status of whether prior treatment for headaches is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Status of whether prior treatment for headaches is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Prior treatment for headache | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54392 | Acute Concussion Evaluation (ACE) - Follow-up action plan physician clinician office monitoring date | ACEFupActPlnPhysClinOffMonDate | Date of physician/clinician office monitoring follow-up plan of action for subject/participant as related to the Acute Concussion Evaluation (ACE) | Date of physician/clinician office monitoring follow-up plan of action for subject/participant as related to the Acute Concussion Evaluation (ACE | Physician/Clinician Office Monitoring: Date of next follow-up | Date or Date & Time | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
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| C54347 | Acute Concussion Evaluation (ACE) - Seizure indicator | ACESeizureInd | Indicator of whether subject/participant had seizures as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant had seizures as related to the Acute Concussion Evaluation (ACE | Seizures: Were seizures observed? | No;Yes | No;Yes | Alphanumeric |
Indicate whether seizures were observed or not. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C00008 | Age value | AgeVal | Value for participant's age, calculated as elapsed time since the birth of the participant | Value for participant's age, calculated as elapsed time since the birth of the participant | Age | Numeric Values | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Pediatric | Supplemental | 3.10 | 2024-02-29 15:47:28.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
0 | 1800 | month | ||||||||
| C54358 | Acute Concussion Evaluation (ACE) - Symptom check list total symptom score | ACESymptomChkLstTotSympScore | Total score of the sum of physical, cognitive, emotional, and sleep symptoms the subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE) | Total score of the sum of physical, cognitive, emotional, and sleep symptoms the subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE | Total Symptom Score (0-22) | Numeric Values |
Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
0 | 22 | ||||||||
| C54337 | Acute Concussion Evaluation (ACE) - Injury cause type | ACEInjuryCauseTyp | Type of injury cause as related to the Acute Concussion Evaluation (ACE) | Type of injury cause as related to the Acute Concussion Evaluation (ACE | Cause | Assault;Fall;MVC;Other;Pedestrian-MVC;Sports | Assault;Fall;Motor Vehicle Crash;Other;Pedestrian-Motor Vehicle Crash;Sports | Alphanumeric |
Greater forces associated with the trauma are likely to result in more severe presentation of symtoms. Indicate cause of injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54369 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery migraine headache type | ACERskFcPrtrctRcvMigrneHeadTyp | Type of migraine headache as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Type of migraine headache as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | History of migraine headache | Family;Personal | Family;Personal | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54393 | Acute Concussion Evaluation (ACE) - Follow-up action plan referral type | ACEFollowupActPlanReferralTyp | Type follow-up plan of action referral for subject/participant as related to the Acute Concussion Evaluation (ACE) | Type follow-up plan of action referral for subject/participant as related to the Acute Concussion Evaluation (ACE | Referral: | Emergency department;Neuropsychological Testing;Physician | Emergency department;Neuropsychological Testing;Physician | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54348 | Acute Concussion Evaluation (ACE) - Seizure detail text | ACESeizureDetailTxt | Text describing subject/participant seizures as related to the Acute Concussion Evaluation (ACE) | Text describing subject/participant seizures as related to the Acute Concussion Evaluation (ACE | Observed seizure detail | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C05400 | Injury date time | InjDateTime | Date (and time, if applicable and known) of injury | Date (and time, if applicable and known) of injury | Date/Time of Injury | Date or Date & Time | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 3.00 | 2013-07-20 10:21:25.65 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
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| C54359 | Acute Concussion Evaluation (ACE) - Symptom check list exertion physical activity indicator | ACESymptomChkLstExrtPhysActInd | Indicator of whether subject/participant symptoms worsen with physical activity since injury as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant symptoms worsen with physical activity since injury as related to the Acute Concussion Evaluation (ACE | Exertion: Do these symptoms worsen with physical activity? | Yes;No;N/A | Yes;No;N/A | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54338 | Acute Concussion Evaluation (ACE) - Injury cause type sports text | ACEInjuryCauseTypSportsTxt | Text specifying the cause of the impact injury as related to the Acute Concussion Evaluation (ACE) | Text specifying the cause of the impact injury as related to the Acute Concussion Evaluation (ACE | Sports (specify) | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54370 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery migraine headache family text | ACERskFcPtrctRcvMgrnHeadFamTxt | Text describing which family member(s) had/have migraine headache as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Text describing which family member(s) had/have migraine headache as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Provide detail of family members with history of migraine | Alphanumeric |
Provide detail of family members with history of migraine |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 100 |
Free-Form Entry |
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| C54394 | Acute Concussion Evaluation (ACE) - Follow-up action plan referral physician type | ACEFollowupActPlnReferPhyscTyp | Type follow-up plan of action referral physician for subject/participant as related to the Acute Concussion Evaluation (ACE) | Type follow-up plan of action referral physician for subject/participant as related to the Acute Concussion Evaluation (ACE | Physician: | Neurology;Neurosurgery;Other;Physiatrist;Psychiatrist;Sports Medicine | Neurology;Neurosurgery;Other;Physiatrist;Psychiatrist;Sports Medicine | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54349 | Acute Concussion Evaluation (ACE) - Symptom check list type | ACESymptomChkLstTyp | Type of symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE) | Type of symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE | Since the injury, has the person experienced any of these symptoms any more than jusual today or in the past day? | Balance problems;Difficulty concentrating;Difficulty remembering;Dizziness;Drowsiness;Fatigue;Feeling mentally foggy;Feeling slowed down;Headache;Irritability;More emotional;Nausea;Nervousness;Numbness/tingling;Sadness;Sensitivity to light;Sensitivity to noise;Sleeping less than usual;Sleeping more than usual;Trouble falling asleep;Visual problems;Vomiting | Balance problems;Difficulty concentrating;Difficulty remembering;Dizziness;Drowsiness;Fatigue;Feeling mentally foggy;Feeling slowed down;Headache;Irritability;More emotional;Nausea;Nervousness;Numbness/tingling;Sadness;Sensitivity to light;Sensitivity to noise;Sleeping less than usual;Sleeping more than usual;Trouble falling asleep;Visual problems;Vomiting | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. Lovell MR, Collins MW. Neuropsychological assessment of the college football player. J Head Trauma Rehabil. 1998;13(2):9-26. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C17409 | Visit date | VisitDate | Date of interview or visit (actually the date when data in the form were captured) | Date of interview or visit | Date: | Date or Date & Time | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 3.00 | 2013-06-21 00:00:00.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
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| C54360 | Acute Concussion Evaluation (ACE) - Symptom check list exertion cognitive activity indicator | ACESymptomChkLstExrtCognActInd | Indicator of whether subject/participant symptoms worsen with cognitive activity since injury as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant symptoms worsen with cognitive activity since injury as related to the Acute Concussion Evaluation (ACE | Exertion: Do these symptoms worsen with cognitive activity? | Yes;No;N/A | Yes;No;N/A | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54371 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery developmental history type | ACERskFacProtrctRcvDevlopHxTyp | Type of developmental history as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Type of developmental history as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Developmental History | Attention Deficit Hyperactivity Disorder (ADHD);Learning disability;Other developmental disorder | Attention Deficit Hyperactivity Disorder (ADHD);Learning disability;Other developmental disorder | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54339 | Acute Concussion Evaluation (ACE) - Injury cause type other text | ACEInjuryCauseTypOthrTxt | Text specifying another cause of the impact injury as related to the Acute Concussion Evaluation (ACE) | Text specifying another cause of the impact injury as related to the Acute Concussion Evaluation (ACE | Other | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54395 | Acute Concussion Evaluation (ACE) - Follow-up action plan referral physician type other text | ACEFlowupActPlnReferPhysTypOTH | Test of other type follow-up plan of action referral physician for subject/participant as related to the Acute Concussion Evaluation (ACE) | Test of other type follow-up plan of action referral physician for subject/participant as related to the Acute Concussion Evaluation (ACE | Other | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54350 | Acute Concussion Evaluation (ACE) - Symptom check list physical indicator | ACESymptomChkLstPhysInd | Indicator of whether subject/participant has experienced physical symptoms since injury as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant has experienced physical symptoms since injury as related to the Acute Concussion Evaluation (ACE | PHYSICAL (0-10) | 0;1 | 0=No;1=Yes | Alphanumeric |
Indicate presence of each symptom (0=No 1=Yes). |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C19247 | Subject ID | SubIDNam | Subject identification ID | Subject identification ID | ID/MR# | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2014-06-05 13:10:49.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54361 | Acute Concussion Evaluation (ACE) - Symptom check list overall rating status | ACESympChkLstOverallRateStat | Status of how different the subject/participant is acting from usual self after injury as related to the Acute Concussion Evaluation (ACE) | Status of how different the subject/participant is acting from usual self after injury as related to the Acute Concussion Evaluation (ACE | Overall Rating: How different is the person acting compared to his/her usual self? | 0;1;2;3;4;5;6 | 0 - Normal;1;2;3;4;5;6 - Very Different | Alphanumeric |
Circle "0" (Normal) to "6" (Very Different) |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-28 12:25:41.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54372 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery other developmental disorder other text | ACERskFacPrtrctRcvOthDevlDsOTH | Text describing other developmental disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Text describing other developmental disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Other developmental disorder | Alphanumeric |
Specify the other developmental disorder. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54340 | Acute Concussion Evaluation (ACE) - Amnesia before no memory events indicator | ACEAmnesiaBfNoMemEvntsInd | Indicator of whether subject/participant had no memory of events before (retrograde) amnesia as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant had no memory of events before (retrograde) amnesia as related to the Acute Concussion Evaluation (ACE | Amnesia Before (Retrograde) Are there any events just BEFORE th einjury that you/person has no memory of (even brief)? | No;Yes | No;Yes | Alphanumeric |
Even seconds to minutes of memory loss can be predictive of outcome. Recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute). |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54396 | Acute Concussion Evaluation (ACE) - ACE reporter text | ACEReporterTxt | Person/individual administering the Acute Concussion Evaluation (ACE) | Person/individual administering the Acute Concussion Evaluation (ACE | ACE completed by: | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54351 | Acute Concussion Evaluation (ACE) - Symptom check list physical total count | ACESymptomChkLstPhysTotCt | Total count of physical symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE) | Total count of physical symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE | PHYSICAL Total (0-10) | Numeric Values |
Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
0 | 10 | ||||||||
| C21117 | Subject name | SubjectName | Name of subject/participant | Name of subject/participan | Patient Name | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2015-06-12 15:16:39.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54362 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery history type | ACERiskFacProtrctRecovHxTyp | Type of risk factors that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Type of risk factors that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Risk Factors for Protracted Recovery | Concussion History;Headache History;Developmental History;Psychiatric History | Concussion History;Headache History;Developmental History;Psychiatric History | Alphanumeric |
Check all that apply |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54375 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery psychiatric history type | ACERskFacPrtrctRcvPsychHxTyp | Type psychiatric history disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Type psychiatric history disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Psychiatric History | Anxiety;Depression;Other psychiatric disorder;Sleep disorder | Anxiety;Depression;Other psychiatric disorder;Sleep disorder | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54341 | Acute Concussion Evaluation (ACE) - Amnesia before no memory events duration | ACEAmnesiaBfNoMemEvntsDur | Duration of subject's/participant's length of amnesia before injury as related to the Acute Concussion Evaluation (ACE) | Duration of subject's/participant's length of amnesia before injury as related to the Acute Concussion Evaluation (ACE | Amnesia Before (Retrograde) Duration | Numeric Values | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
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| C54352 | Acute Concussion Evaluation (ACE) - Symptom check list cognitive indicator | ACESymptomChkLstCogntvInd | Indicator of whether subject/participant has experienced cognitive symptoms since injury as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant has experienced cognitive symptoms since injury as related to the Acute Concussion Evaluation (ACE | COGNITIVE (4) | 0;1 | 0=No;1=Yes | Alphanumeric |
Indicate presence of each symptom (0=No 1=Yes). |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54331 | Acute Concussion Evaluation (ACE) - Person obtaining report type | ACEPersonObtRprtTyp | The type indicating who the report was obtained by, as part of the Acute Concussion Evaluation (ACE) | The type indicating who the report was obtained by, as part of the Acute Concussion Evaluation (ACE) | Reporter: | Patient;Parent;Spouse;Other | Patient;Parent;Spouse;Other | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2016-12-05 10:04:25.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54363 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery concussion history indicator | ACERiskFacProtrctRecvConcHxTyp | Indicator of whether concussion history is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Indicator of whether concussion history is a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Concussion History? | No;Yes | No;Yes | Alphanumeric |
Assess the number and date(s) of prior concussions, duration of symptoms for each injury, and whether less biomechanical force resulted in re-injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54377 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery other psychiatric disorder other text | ACERskFacPrtrctRcvPsycDsordOTH | Text for other psychiatric disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Text for other psychiatric disorder as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Other psychiatric disorder | Alphanumeric |
Specify other psychiatric disorder. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 100 |
Free-Form Entry |
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| C54342 | Acute Concussion Evaluation (ACE) - Amnesia after no memory events indicator | ACEAmnesiaAftrNoMemEvntsInd | Indicator of whether subject/participant had no memory of events after (anterograde) amnesia as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant had no memory of events after (anterograde) amnesia as related to the Acute Concussion Evaluation (ACE | Amnesia After (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)? | No;Yes | No;Yes | Alphanumeric |
Even seconds to minutes of memory loss can be predictive of outcome. Recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute). |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54353 | Acute Concussion Evaluation (ACE) - Symptom check list cognitive total count | ACESymptomChkLstCogntvTotCt | Total count of cognitive symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE) | Total count of cognitive symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE | COGNITIVE Total (0-4) | Numeric Values |
Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
0 | 4 | ||||||||
| C54332 | Person obtaining report other text | PersonObtRprtOtherText | Text specifying another means of obtaining the report | Text specifying another means of obtaining the report | Other | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2016-12-05 10:11:55.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54364 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery concussion history previous value | ACERskFacPrtrctRcvCncHxPrevVal | Value of the number of previous concussions as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Value of the number of previous concussions as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Previous # | 1;2;3;4;5;6+ | 1;2;3;4;5;6+ | Numeric Values |
Assess the number and date(s) of prior concussions, duration of symptoms for each injury, and whether less biomechanical force resulted in re-injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54378 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery comorbid medical disorders medication usage text | ACERskFcPtrctRcvComrdDisMedTxt | Text for other comorbid medical disorders or medication usage as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Text for other comorbid medical disorders or medication usage as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | List other comorbid medical disorders or medication usage (e.g., hypothyroid, seizures) | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54343 | Acute Concussion Evaluation (ACE) - Amnesia after no memory events duration | ACEAmnesiaAftrNoMemEvntsDur | Duration of subject's/participant's length of amnesia after (anterograde) injury as related to the Acute Concussion Evaluation (ACE) | Duration of subject's/participant's length of amnesia after (anterograde) injury as related to the Acute Concussion Evaluation (ACE | Amnesia After (Anterograde) Duration | Numeric Values | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
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| C54354 | Acute Concussion Evaluation (ACE) - Symptom check list emotional indicator | ACESymptomChkLstEmotnlInd | Indicator of whether subject/participant has experienced emotional symptoms since injury as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant has experienced emotional symptoms since injury as related to the Acute Concussion Evaluation (ACE | EMOTIONAL (4) | 0;1 | 0=No;1=Yes | Alphanumeric |
Indicate presence of each symptom (0=No 1=Yes). |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54333 | Acute Concussion Evaluation (ACE) ? Injury description text | ACEInjuryDescriptnTxt | Text of injury description as related to the Acute Concussion Evaluation (ACE) | Text of injury description as related to the Acute Concussion Evaluation (ACE) | Injury Description | Alphanumeric |
Obtain description of the injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 19:20:57.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points | 255 |
Free-Form Entry |
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| C54365 | Acute Concussion Evaluation (ACE) - Risk factors protracted recovery concussion history duration type | ACERskFacPrtrctRcvConcHxDurTyp | Type of duration of longest symptom regarding concussion history as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE) | Type of duration of longest symptom regarding concussion history as a risk factor that may protract the subject/participant recovery process since injury as related to the Acute Concussion Evaluation (ACE | Longest symptom duration | Days;Weeks;Months;years | Days;Weeks;Months;years | Alphanumeric |
Assess the number and date(s) of prior concussions, duration of symptoms for each injury, and whether less biomechanical force resulted in re-injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54380 | Acute Concussion Evaluation (ACE) - Red flags acute emergency management type | ACERedFlagAcuteEmergMgmtTyp | Type of red flags for acute emergency management as related to the Acute Concussion Evaluation (ACE) | Type of red flags for acute emergency management as related to the Acute Concussion Evaluation (ACE | RED FLAGS for acute emergency management: | Can't recognize people or places;Change in state of consciousness;Focal neurologic signs;Headaches that worsen;Increasing confusion or irritability;Looks very drowsy/ can't be awakened;Neck pain;Repeated vomiting;Seizures;Unusual behavioral change;Weakness or numbness in arms/legs | Can't recognize people or places;Change in state of consciousness;Focal neurologic signs;Headaches that worsen;Increasing confusion or irritability;Looks very drowsy/ can't be awakened;Neck pain;Repeated vomiting;Seizures;Unusual behavioral change;Weakness or numbness in arms/legs | Alphanumeric |
Refer to the emergency department with sudden onset of any of the following: |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:22:56.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Multiple Pre-Defined Values Selected |
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| C54344 | Acute Concussion Evaluation (ACE) - Loss of consciousness indicator | ACELossConsciousnessInd | Indicator of whether subject/participant had loss of consciousness as related to the Acute Concussion Evaluation (ACE) | Indicator of whether subject/participant had loss of consciousness as related to the Acute Concussion Evaluation (ACE | Loss of consciousness: Did you/ person lose consciousness? | No;Yes | No;Yes | Alphanumeric | Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Single Pre-Defined Value Selected |
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| C54355 | Acute Concussion Evaluation (ACE) - Symptom check list emotional total count | ACESymptomChkLstEmotnlTotCt | Total count of emotional symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE) | Total count of emotional symptoms subject/participant has experienced since injury as related to the Acute Concussion Evaluation (ACE | EMOTIONAL Total (0-4) | Numeric Values |
Sum total number of symptoms present per area, and sum all four areas into a Total Symptom Score (score range 0–22)(Note: most sleep symptoms are only applicable after a night has passed since the injury. |
Centers for the Disease Control and Prevention. Heads Up: Brain Injury in Your Practice Tool Kit, 2006. | Adult;Pediatric | Supplemental | 1.00 | 2017-02-27 20:29:51.0 | Acute Concussion Evaluation (ACE) | Cognitive Assessment | Outcomes and End Points |
Free-Form Entry |
0 | 4 |
