Data Dictionary Demo - Stroke
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Patient-reported Form
Please complete all required fields marked with an asterisk (*)
Ethnicity
Varies by country and should be determined by country (not for cross country comparison)
Living location pre index event
Where were you living prior to your stroke or transient ischaemic attack (TIA)? Most recent place of residence pre stroke
-- Please select --
At home, with no community support
At home with community support
In an assisting living home in the community (senior's home)
In a rehabilitation hospital or skilled care facilities (SNIF, IRF, LTACH)
In long term care (nursing home, chronic care hospital)
Other
Unknown
Living location post index event
Where are you living now?
-- Please select --
At home, with no community support
At home with community support
In an assisting living home in the community (senior's home)
In a rehabilitation hospital or skilled care facilities (SNIF, IRF, LTACH)
In long term care (nursing home, chronic care hospital
In an acute care hospital
Other
Unknown
Living alone pre-index event
Did you live alone prior to your stroke or transient ischaemic attack (TIA)?
Yes, I lived alone
No, I shared my household with spouse/partner or other person (e.g. sibling, children, parents)
Unknown
Living alone post-index event
Do you live alone now?
Yes, I live alone
No, I share my household with spouse/partner or other person (e.g. sibling, children, parents)
Unknown
Prestroke functional status - Ambulation
Were you able to walk prior to your stroke or transient ischaemic attack (TIA)?
Able to walk without help from another person with or without a device
Able to walk with help from another person
Unable to walk
Prestroke functional status - Toileting
Did you need help from anybody to go to the toilet prior to your stroke or transient ischaemic attack (TIA)?
I could manage going to the toilet without assistance
I needed help to go to the toilet
Prestroke functional status - Dressing
Did you need help with dressing/undressing prior to your stroke or transient ischaemic attack (TIA)?
I could manage dressing/undressing without help
I needed help dressing/undressing
Smoking status
Do you currently smoke, or have you smoked cigarettes or tobacco over the past year? Smoking status (of cigarettes or tobacco). Item is phrased as a patient reported measure. However, if the patient is unable to answer, this information can be abstracted from the medical records.
No
Yes
Unknown
Smoking cessation
Since your hospitalization for stroke, have you smoked tobacco or cigarettes?
No
Yes
Unknown
Poststroke functional status - Ambulation
Are you able to walk? This item is also measured at baseline, as PRESTROKEAMB
Able to walk without help from another person with or without a device
Able to walk with help from another person
Unable to walk
Poststroke functional status - Toileting
Do you need help from anybody to go to the toilet? This item is also measured at baseline, as PRESTROKETOILET
I can manage going to the toilet without assistance
I need help to go to the toilet
Poststroke functional status - Dressing
Do you need help with dressing/undressing? This item is also measured at baseline, as PRESTROKEDRESS
I can manage dressing/undressing without help
I need help dressing/undressing
Feeding
Do you need a tube for feeding? For example: a nasogastric tube or a gastrostomy tube
No
Yes
Ability to communicate
Do you have problems with communication or understanding?
No
Yes
General
In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
In general, would you say your quality of life is:
Excellent
Very good
Good
Fair
Poor
In general, how would you rate your physical health?
Excellent
Very good
Good
Fair
Poor
In general, how would you rate your mental health, including your mood and your ability to think?
Excellent
Very good
Good
Fair
Poor
In general, how would you rate your satisfaction with your social activities and relationships?
Excellent
Very good
Good
Fair
Poor
In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)
Excellent
Very good
Good
Fair
Poor
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?
Completely
Mostly
Moderately
A little
Not at all
In the past 7 days, how often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?
Never
Rarely
Sometimes
Often
Always
In the past 7 days, how would you rate your fatigue on average?
None
Mild
Moderate
Severe
Very severe
In the past 7 days, how would you rate your pain on average? Indicate pain level on a scale of 0-10, where 0 = No pain, and 10 = Worst imaginable pain
Numerical value between 0 and 10
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