NACC UDS Initial Visit Packet Data Element Dictionary
|
|
|
- Rodger Barker
- 5 years ago
- Views:
Transcription
1 Department of Epidemiology, School of Public Health and Community Medicine, University of Washington th Avenue NE #300 Seattle, WA phone: (206) ; fax: (206) website: NACC UDS Initial Visit Packet Data Element Dictionary (.2, March 2006) NOTE:.2 is NOT the most current version of the UDS forms and is no longer used for data submission. For the most current version, please visit This publication was funded by the National Institutes of Health through the National Institute on Aging (Cooperative Agreement #AG016976)
2 Data Element Dictionary UDS Initial Visit Packet Indicates order of appearance on the UDS form. For non-fixed-format files, variable name must match exactly. Version 1 Used on the web page to indicate variable. Question The question as it appears on the UDS form. Length of Field For fixed field formats, number of columns for this variable. Column Positions For fixed field formats, column numbers for this variable. For non-fixed field formats, variable type as numerical or character. List of codes with mapping instructions. and Skips Instructions for skip patterns. Comments Other instructions as needed. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 1
3 Form: Header (All Initial Visit Packet forms) 0A PACKET Packet code Length of Field 2 Column Positions 1 2 Character I = Initial Visit Packet 0B FORMID Form ID Length of Field 3 Column Positions 4 6 Character A1 A5 B1 B9 C1 D1 E1 Z1 0C FORMVER Form version number Length of Field 3 Column Positions 8 10 See bottom of current form, use integer portion of version number. Comment For example, version 1.1 is FORMVER = 1. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 2
4 Form: Header (All Initial Visit Packet forms) 0D ADCID Center ID Length of Field 2 Column Positions , Use code below as your Center ID: 1 = BAYLOR 2 = BOSTON U 3 = CASE WESTERN 4 = COLUMBIA 5 = DUKE 6 = EMORY 7 = MASSACHUSETTS GENERAL HOSPITAL 8 = INDIANA U 9 = JOHNS HOPKINS 10 = MAYO 11 = MOUNT SINAI 12 = NEW YORK U 13 = NORTHWESTERN 14 = OREGON HEALTH SCIENCES 15 = RUSH U 16 = U CALIFORNIA, DAVIS 17 = U CALIFORNIA, LOS ANGELES 18 = U CALIFORNIA, SAN DIEGO 19 = U KENTUCKY 20 = U MICHIGAN 21 = U PENNSYLVANIA 22 = U PITTSBURGH 23 = U ROCHESTER 25 = U TEXAS SOUTHWESTERN 26 = U WASHINGTON 27 = WASHINGTON U, SAINT LOUIS 28 = U ALABAMA 30 = U SOUTHERN CALIFORNIA 31 = U CALIFORNIA, IRVINE 32 = STANFORD 33 = ARIZONA 34 = U ARKANSAS 35 = U CALIFORNIA, SAN FRANCISCO 36 = FLORIDA Comment Note: ADCID is converted to a randomly-generated Center ID in the non-adc researcher data set (PUBADCID). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 3
5 Form: Header (All Initial Visit Packet forms) 0E 0 PTID Column Positions Comment ADC Subject ID ADC Subject ID Character Follow your Center s Patient ID scheme; use same ID as in MDS, if enrolled in MDS. Number must be unique within data from you Center, and be used for each visit for subject. Note: PTID is not available to non-adc researchers. It is replaced in the accessible UDS database by a randomlygenerated NACC ID (PUBLICID). 0F VISITMO Visit Date month Visit Date Length of Field 2 Column Positions Comment Visit date cannot precede September 1, G VISITDAY Visit Date day Visit Date Length of Field 2 Column Positions Comment Visit date cannot precede September 1, Note: VISITDAY is not available to non-adc researchers. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 4
6 Length of Field 4 Form: Header (All Initial Visit Packet forms) 0H VISITYR Visit Date year Visit Date Column Positions to present year Comment Visit date cannot precede September 1, I VISITNUM ADC Visit ID ADC Visit # Length of Field 3 Column Positions Character Can be determined by the Center. Comment The Center can use its existing visit number scheme, if desired. It is NOT required to start with 1. Leave blank for Form M1. 0J INITIALS Examiner s initials Examiner s initials Length of Field 3 Column Positions Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&) or percentage signs (%). Note: INITIALS is not available to non-adc researchers. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 5
7 1 Column Positions 45 Length of Field 2 A2SUB Form Z1: Form Checklist Form A2 submitted Form A2, Informant Demographics submitted 0 = No 1 = Yes 1A A2NOT Column Positions Reason Form A2 not submitted Reason Form A2, Informant Demographics not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #1, A2SUB = 1 (Yes). 1B Length of Field 60 A2COMM Column Positions Form A2 comments Form A2, Informant Demographics, comments (provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 6
8 Form Z1: Form Checklist 2 A3SUB Form A3 submitted Form A3, Subject Family History submitted Column Positions = No 1 = Yes 2A A3NOT Reason Form A3 not submitted Reason Form A3, Subject Family History not submitted Length of Field 2 Column Positions = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #2, A3SUB = 1 (Yes). 2B Length of Field 60 A3COMM Form A3 comments Column Positions Form A3, Subject Family History, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 7
9 Form Z1: Form Checklist 3 Column Positions 177 Length of Field 2 A4SUB Form A4 submitted Form A4, Subject Medications submitted 0 = No 1 = Yes 3A A4NOT Column Positions Reason Form A4 not submitted Reason Form A4, Subject Medications not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #3, A4SUB = 1 (Yes). 3B Length of Field 60 A4COMM Form A4 comments Column Positions Form A4, Subject Medications, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 8
10 Form Z1: Form Checklist 4 Column Positions 243 Length of Field 2 B1SUB Form B1 submitted Form B1, Evaluation Form Physical submitted 0 = No 1 = Yes 4A B1NOT Column Positions Reason Form B1 not submitted Reason Form B1, Evaluation Form Physical not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #4, B1SUB = 1 (Yes). 4B Length of Field 60 B1COMM Form B1 comments Column Positions Form B1, Evaluation Form Physical, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 9
11 Form Z1: Form Checklist 5 Column Positions 309 Length of Field 2 B2SUB Form B2 submitted Form B2, Evaluation Form Hachinski Ischemic Scale submitted 0 = No 1 = Yes 5A B2NOT Column Positions Reason Form B2 not submitted Reason Form B2, Evaluation Form Hachinski Ischemic Scale not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #5, B2SUB = 1 (Yes). 5B Length of Field 60 B2COMM Form B2 comments Column Positions Form B2, Evaluation Form Hachinski Ischemic Scale, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 10
12 Form Z1: Form Checklist 6 Column Positions 375 Length of Field 2 B3SUB Form B3 submitted Form B3, Evaluation Form UPDRS submitted 0 = No 1 = Yes 6A B3NOT Column Positions Reason Form B3 not submitted Reason Form B3 Evaluation Form UPDRS not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #6, B3SUB = 1 (Yes). 6B Length of Field 60 B3COMM Form B3 comments Column Positions Form B3, Evaluation Form UPDRS, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 11
13 Form Z1: Form Checklist 7 Column Positions 441 Length of Field 2 B5SUB Form B5 submitted Form B5, Behavioral Assessment NPI-Q submitted 0 = No 1 = Yes 7A B5NOT Column Positions Reason Form B5 not submitted Reason Form B5, Behavioral Assessment NPI-Q not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #7, B5SUB = 1 (Yes). 7B Length of Field 60 B5COMM Form B5 comments Column Positions Form B5, Behavioral Assessment NPI-Q, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 12
14 Form Z1: Form Checklist 8 Column Positions 507 Length of Field 2 B6SUB Form B6 submitted Form B6, Behavioral Assessment GDS submitted 0 = No 1 = Yes 8A B6NOT Column Positions Reason Form B6 not submitted Reason Form B6, Behavioral Assessment GDS not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #8, B6SUB = 1 (Yes). 8B Length of Field 60 B6COMM Form B6 comments Column Positions Form B6, Behavioral Assessment GDS, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 13
15 Form Z1: Form Checklist 9 Column Positions 573 Length of Field 2 B7SUB Form B7 submitted Form B7, Functional Assessment FAQ submitted 0 = No 1 = Yes 9A B7NOT Column Positions Reason Form B7 not submitted Reason Form B7, Functional Assessment FAQ not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #9, B7SUB = 1 (Yes). 9B Length of Field 60 B7COMM Form B7 comments Column Positions Form B7, Functional Assessment FAQ, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 14
16 Form Z1: Form Checklist 10 Column Positions 639 Length of Field 2 B8SUB Form B8 submitted Form B8, Evaluation Physical/Neurological Exam Findings 0 = No 1 = Yes 10A B8NOT Column Positions Reason Form B8 not submitted Reason Form B8, Evaluation Physical/Neurological Exam Findings not submitted 95 = Physical problem 96 = Cognitive/behavior problem 97 = Other problem 98 = Verbal refusal Blank if #10, B8SUB = 1 (Yes). 10B Length of Field 60 B8COMM Form B8 comments Column Positions Form B8, Evaluation Physical/Neurological Exam Findings, comments(provide if needed) Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 15
17 1 Column Positions 45 2 Column Positions 47 Form A1: Subject Demographics INMDS Subject in MDS Subject enrolled in NACC MDS 0 = No 1 = Yes REASON Primary reason for coming to ADC Primary reason for coming to ADC 1 = Participate in research study 2 = Clinical evaluation 3 = Other 9 = Unknown 2A Length of Field 60 REASONX Column Positions Other primary reason specify Other primary reason for coming to ADC specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #2, REASON not coded 3 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 16
18 Form A1: Subject Demographics 3 Column Positions 110 REFER Principal referral source Principal referral source 1 = Self/relative/friend 2 = Clinician 3 = ADC solicitation 4 = Non-ADC study 5 = Clinic sample 6 = Population sample 7 = Non-ADC media appeal (e.g. Alzheimer s Association) 8 = Other 9 = Unknown 3A Length of Field 60 REFERX Column Positions Principal referral source, other specify Principal referral source, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #3, REFER not coded 8 (Other). 4 PRESTAT Presumed disease status at enrollment Presumed disease status at enrollment Column Positions = Case/patient/proband 2 = Control/normal 3 = No presumed disease status NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 17
19 Form A1: Subject Demographics 5 PRESPART Presumed participation Presumed participation Column Positions = Initial evaluation only 2 = Longitudinal follow-up planned 6 SOURCE ADC enrollment type ADC enrollment type Column Positions = Clinical Core 2 = Satellite Core 3 = Other ADC Core/project 4 = Center-affiliated/non-ADC 7A BIRTHMO Subject s month of birth Subject s month of birth Length of Field 2 Column Positions Note: BIRTHMO is not available to non-adc researchers. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 18
20 Length of Field 4 7B Form A1: Subject Demographics BIRTHYR Column Positions Subject s year of birth Subject s year of birth 1875 to (current year minus 15) 8 SEX Column Positions 187 Subject s sex Subject s sex 1 = Male 2 = Female 9A HISPANIC Hispanic/Latino ethnicity Does the subject report being of Hispanic/Latino ethnicity. (i.e., having origins from a mainly Spanish-speaking Latin American country), regardless of race? Column Positions = No 1 = Yes 9 = Unknown Skips If no or unknown, go to #10. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 19
21 Length of Field 2 9B Form A1: Subject Demographics HISPOR Hispanic origins Column Positions If the subject reports being of Hispanic/Latino ethnicity, what are the subject s reported origins? 1 = Mexican/Chicano/Mexican-American 2 = Puerto Rican 3 = Cuban 4 = Dominican 5 = Central American 6 = South American 50 = Other 99 = Unknown Blank if #9A, HISPANIC = 0 (No) or 9 (Unknown). 9B1 Length of Field 60 HISPORX Column Positions Hispanic origins, other specify Hispanic origins, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #9A, HISPANIC = 0 (No) or 9 (Unknown), or if #9B, HISPOR not coded 50 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 20
22 Form A1: Subject Demographics 10 Length of Field 2 RACE Race Column Positions What does subject report as his/her race? 1 = White 2 = Black or African American 3 = American Indian or Alaska Native 4 = Native Hawaiian or Other Pacific Islander 5 = Asian 50 = Other 99 = Unknown 10A Length of Field 60 RACEX Column Positions Race, other specify Race, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #10, RACE not coded 50 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 21
23 Form A1: Subject Demographics 11 Length of Field 2 RACESEC Additional race Column Positions What additional race does subject report? 1 = White 2 = Black or African American 3 = American Indian or Alaska Native 4 = Native Hawaiian or Other Pacific Islander 5 = Asian 50 = Other 88 = None reported 99 = Unknown 11A Length of Field 60 RACESECX Column Positions Additional race, other specify Additional race, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #11, RACESEC not coded 50 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 22
24 Form A1: Subject Demographics 12 Length of Field 2 RACETER Additional race Column Positions What additional race, beyond what was indicated above in questions 10 and 11, does subject report? 1 = White 2 = Black or African American 3 = American Indian or Alaska Native 4 = Native Hawaiian or Other Pacific Islander 5 = Asian 50 = Other 88 = None reported 99 = Unknown 12A Length of Field 60 RACETERX Column Positions Additional race, other specify Additional race, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #12, RACETER not coded 50 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 23
25 Form A1: Subject Demographics 13 Column Positions 447 PRIMLANG Primary language Subject s primary language 1 = English 2 = Spanish 3 = Mandarin 4 = Cantonese 5 = Russian 6 = Japanese 8 = Other primary language 9 = Unknown 13A Length of Field 60 PRIMLANX Column Positions Other primary language - specify Other primary language - specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #13, PRIMLANG not coded 8 (Other primary language). 14 EDUC Education Subject s years of education (report achieved level using the codes below; if an attempted level is not completed, enter the number of years completed): High school/ged = 12; Bachelors degree = 16; Master s degree = 18; Doctorate = 20) Length of Field 2 Column Positions = Unknown NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 24
26 Form A1: Subject Demographics 15 LIVSIT Column Positions 513 Living situation What is the subject s living situation? 1 = Lives alone 2 = Lives with spouse or partner 3 = Lives with relative or friend 4 = Lives with group 5 = Other 9 = Unknown 15A Length of Field 60 LIVSITX Column Positions Living situation, other specify Living situation, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #15, LIVSIT not coded 5 (Other). 16 INDEPEND Level of independence What is the subject s level of independence? Column Positions = Able to live independently 2 = Requires some assistance with complex activities 3 = Requires some assistance with basic activities 4 = Completely dependent 9 = Unknown NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 25
27 Form A1: Subject Demographics 17 Column Positions 578 RESIDENC Type of residence What is the subject s type of residence? 1 = Single family residence 2 = Retirement community 3 = Assisted living/boarding home/adult family home 4 = Skilled nursing facility/nursing home 5 = Other 9 = Unknown 17A Length of Field 60 RESIDENX Column Positions Type of residence, other specify Type of residence, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #17, RESIDENC not coded 5 (Other). 18 ZIP Zip code Subject s primary residence zip code (first 3 digits) Length of Field 3 Column Positions Character Must be valid zip code, in the range Note: ZIP is not available to non-adc researchers. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 26
28 Form A1: Subject Demographics 19 Column Positions 645 MARISTAT Marital status Subject s current marital status 1 = Married 2 = Widowed 3 = Divorced 4 = Separated 5 = Never married 6 = Living as married 8 = Other 9 = Unknown 19A Length of Field 60 MARISTAX Column Positions Marital status, other specify Marital status, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #19, MARISTAT not coded 8 (Other). 20 HANDED Left- or right-handed Is the subject left- or right-handed (for example, which hand would s/he normally use to write or throw a ball)? Column Positions = Left-handed 2 = Right-handed 3 = Ambidextrous 9 = Unknown NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 27
29 Form A2: Informant Demographics 1A INBIRMO Informant s month of birth Informant s month of birth Length of Field 2 Column Positions = Unknown 1B INBIRYR Informant s year of birth Informant s year of birth Length of Field 4 Column Positions to (current year minus 15) 9999 = Unknown 2 INSEX Informant s sex Informant s sex Column Positions 53 1 = Male 2 = Female NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 27
30 3A Form A2: Informant Demographics INHISP Informant Hispanic/Latino ethnicity Does the informant report being of Hispanic/Latino ethnicity (i.e., having origins from a mainly Spanish-speaking Latin American country), regardless of race? Column Positions 55 0 = No 1 = Yes 9 = Unknown Skips If no or unknown, go to #4. 3B INHISPOR Informant Hispanic origins If informant reports being of Hispanic/Latino ethnicity, what are the informant s reported origins? Length of Field 2 Column Positions = Mexican/Chicano/Mexican-American 2 = Puerto Rican 3 = Cuban 4 = Dominican 5 = Central American 6 = South American 50 = Other 99 = Unknown Blank if #3A, INHISP = 0 (No) or 9 (Unknown). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 28
31 Form A2: Informant Demographics 3B1 Length of Field 60 INHISPOX Column Positions Informant of Hispanic origins, other - specify Informant of Hispanic origins, other - specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #3A, INHISP = 0 (No) or 9 (Unknown), or #3B, INHISPOR not coded 50 (Other). 4 INRACE Informant race What does informant report as his/her race? Length of Field 2 Column Positions = White 2 = Black or African American 3 = American Indian or Alaska Native 4 = Native Hawaiian or Other Pacific Islander 5 = Asian 50 = Other 99 = Unknown 4A INRACEX Informant race, other specify Informant race, other specify Length of Field 60 Column Positions Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #4, INRACE not coded 50 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 29
32 5 Length of Field 2 Form A2: Informant Demographics INRASEC Column Positions Informant additional race What additional race does informant report? 1 = White 2 = Black or African American 3 = American Indian or Alaska Native 4 = Native Hawaiian or Other Pacific Islander 5 = Asian 50 = Other 88 = None reported 99 = Unknown 5A Length of Field 60 INRASECX Column Positions Informant additional race, other specify Informant additional race, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #5, INRASEC not coded 50 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 30
33 6 Length of Field 2 Form A2: Informant Demographics INRATER Column Positions Informant additional race What additional race, beyond what was indicated above in questions 4 and 5, does informant report? 1 = White 2 = Black or African American 3 = American Indian or Alaska Native 4 = Native Hawaiian or Other Pacific Islander 5 = Asian 50 = Other 88 = None reported 99 = Unknown 6A Length of Field 60 INRATERX Column Positions Informant additional race, other specify Informant additional race, other specify Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #6, INRATER not coded 50 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 31
34 7 Form A2: Informant Demographics INEDUC Informant education Informant s years of education (report achieved level using the codes below; if an attempted level is not completed, enter the number of years attended). High school/ged = 12; Bachelors degree = 16; Master s degree = 18; Doctorate = 20) Length of Field 2 Column Positions = Unknown 8 INRELTO Informant relationship What is informant s relationship to subject? Column Positions = Spouse/partner 2 = Child 3 = Sibling 4 = Other relative 5 = Friend/neighbor 6 = Paid caregiver/provider 7 = Other 8A INRELTOX Informant relationship, other specify Informant relationship, other specify Length of Field 60 Column Positions Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). Blank if #8, INRELTO not coded 7 (Other). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 32
35 9 Column Positions 379 Form A2: Informant Demographics INLIVWTH Informant live with Does the informant live with the subject? 0 = No 1 = Yes Skips If yes, skip to #10. 9A INVISITS Informant visits If informant does not live with the subject, approximate frequency of in-person visits. Column Positions = Daily 2 = At least 3x/week 3 = Weekly 4 = At least 3x/month 5 = Monthly 6 = Less than once a month Blank if #9, INLIVWTH = 1 (Yes). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 33
36 9B Column Positions Column Positions 385 Form A2: Informant Demographics INCALLS Informant telephone calls If informant does not live with the subject, approximate frequency of telephone contact. 1 = Daily 2 = At least 3x/week 3 = Weekly 4 = At least 3x/month 5 = Monthly 6 = Less than once a month Blank if #9, INLIVWTH = 1 (Yes). INRELY Informant reliability Is there a question about the informant s reliability? 0 = No 1 = Yes NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 34
37 1 Form A3: Subject Family History MOMDEM Mother demented Did the subject s mother have dementia (as defined on form), as indicated by symptoms, history or diagnosis? Column Positions 45 0 = No 1 = Yes 9 = Unknown 1A MOMONSET Mother s age at onset If the subject s mother had dementia, indicate the age at which she developed dementia symptoms (age at onset, as defined on form). Length of Field 3 Column Positions = NA 999 = Unknown 1B MOMAGE Demented mother s age, if living If the subject s mother has dementia and is living, indicate her current age. Length of Field 3 Column Positions = NA 999 = Unknown NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 35
38 1C Form A3: Subject Family History MOMDAGE Demented mother s age at death If the subject s mother had dementia and is deceased, indicate her age at death. Length of Field 3 Column Positions = NA 999 = Unknown 2 DADDEM Father demented Did the subject s father have dementia (as defined on form), as indicated by symptoms, history or diagnosis? Column Positions 59 0 = No 1 = Yes 9 = Unknown 2A DADONSET Father s age at onset If the subject s father had dementia, indicate the age at which he developed dementia symptoms (age at onset, as defined on form). Length of Field 3 Column Positions = NA 999 = Unknown NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 36
39 Length of Field 3 2B Form A3: Subject Family History DADAGE Column Positions Demented father s age, if living If the subject s father has dementia and is living, indicate his current age = NA 999 = Unknown 2C DADDAGE Demented father s age at death If the subject s father had dementia and is deceased, indicate his age at death. Length of Field 3 Column Positions = NA 999 = Unknown 3 TWIN Is the subject a twin Is the subject a twin? Column Positions 73 0 = No 1 = Yes 9 = Unknown NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 37
40 3A Column Positions 75 4 Length of Field 2 Form A3: Subject Family History TWINTYPE Type of twin If the subject is a twin, indicate type. 1 = Monozygotic (i.e., identical) 2 = Dizygotic (i.e., fraternal) 8 = N/A 9 = Unknown SIBS Siblings Column Positions How many full siblings did the subject have? = Unknown SIBSDEM Siblings demented How many of these siblings had dementia (as defined on form), as indicated by symptoms, history or diagnosis? Length of Field 2 Column Positions = N/A 99 = Unknown NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 38
41 Form A3: Subject Family History 5A1 SIB1ONS Sibling 1 age at onset Sibling 1 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. 5A2 SIB1AGE Sibling 1 current age if living Sibling 1 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. 5B1 SIB2ONS Sibling 2 age at onset Sibling 2 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 39
42 Form A3: Subject Family History 5B2 SIB2AGE Sibling 2 current age if living Sibling 2 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. 5C1 SIB3ONS Sibling 3 age at onset Sibling 3 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. 5C2 SIB3AGE Sibling 3 current age if living Sibling 3 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 40
43 Form A3: Subject Family History 5D1 SIB4ONS Sibling 4 age at onset Sibling 4 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. 5D2 SIB4AGE Sibling 4 current age if living Sibling 4 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. 5E1 SIB5ONS Sibling 5 age at onset Sibling 5 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 41
44 Form A3: Subject Family History 5E2 SIB5AGE Sibling 5 current age if living Sibling 5 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. 5F1 SIB6ONS Sibling 6 age at onset Sibling 6 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. 5F2 SIB6AGE Sibling 6 current age if living Sibling 6 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #5, SIBSDEM = 0, 88 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 42
45 Form A3: Subject Family History 6 Length of Field 2 KIDS Children of subject Column Positions How many biological children did the subject have? = Unknown KIDSDEM Children demented How many of these children had dementia (as defined on form), as indicated by symptoms, history or diagnosis? Length of Field 2 Column Positions = N/A 99 = Unknown 7A1 KID1ONS Child 1 age at onset Child 1 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 43
46 Form A3: Subject Family History 7A2 KID1AGE Child 1 current age if living Child 1 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. 7B1 KID2ONS Child 2 age at onset Child 2 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. 7B2 KID2AGE Child 2 current age if living Child 2 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 44
47 Form A3: Subject Family History 7C1 KID3ONS Child 3 age at onset Child 3 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. 7C2 KID3AGE Child 3 current age if living Child 3 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. 7D1 KID4ONS Child 4 age at onset Child 4 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 45
48 Form A3: Subject Family History 7D2 KID4AGE Child 4 current age if living Child 4 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. 7E1 KID5ONS Child 5 age at onset Child 5 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. 7E2 KID5AGE Child 5 current age if living Child 5 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 46
49 Length of Field 3 7F1 Form A3: Subject Family History KID6ONS Child 6 age at onset Child 6 age at onset Column Positions = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or 99. Length of Field 3 7F2 KID6AGE Column Positions Child 6 current age if living Child 6 current age if living = N/A 999 = Age unknown Blank if #7, KIDSDEM = 0, 88 or RELSDEM Relatives demented Number of other blood relatives with dementia (as defined on form) (cousins, aunts, uncles, grandparents, half siblings), as indicated by symptoms, history or diagnosis. Length of Field 2 Column Positions = Unknown NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 47
50 Form A3: Subject Family History 8A1 REL1ONS Relative 1 age at onset Relative 1 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. 8A2 REL1AGE Relative 1 current age if living Relative 1 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. 8B1 REL2ONS Relative 2 age at onset Relative 2 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 48
51 Form A3: Subject Family History 8B2 REL2AGE Relative 2 current age if living Relative 2 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. 8C1 REL3ONS Relative 3 age at onset Relative 3 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. 8C2 REL3AGE Relative 3 current age if living Relative 3 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 49
52 Form A3: Subject Family History 8D1 REL4ONS Relative 4 age at onset Relative 4 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. 8D2 REL4AGE Relative 4 current age if living Relative 4 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. 8E1 REL5ONS Relative 5 age at onset Relative 5 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 50
53 Form A3: Subject Family History 8E2 REL5AGE Relative 5 current age if living Relative 5 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. 8F1 REL6ONS Relative 6 age at onset Relative 6 age at onset Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. 8F2 REL6AGE Relative 6 current age if living Relative 6 current age if living Length of Field 3 Column Positions = N/A 999 = Age unknown Blank if #8, RELSDEM = 0 or 99. NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 51
54 1 Column Positions 45 PMEDS Form A4: Subject Medications Current prescription medications Is the subject currently taking any prescription medications? 0 = No 1 = Yes 1A PMA Length of Field 30 Column Positions Length of Field 5 Prescription medication A name Prescription medication A name Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). 1A1 PMAS Column Positions Prescription medication A strength Prescription medication A strength > 0.00 to (decimals allowed) 1A2 Column Positions 84 PMASU Prescription medication A strength units Prescription medication A strength units 1 = µg 2 = mg 3 = ml 4 = IU NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 52
55 1A3 PMAF Form A4: Subject Medications Prescription medication A frequency Prescription medication A frequency: total number of doses per day, week or month Length of Field 2 Column Positions > 0 to 99 Blank if #1A5, PMAP = 1 (Yes). 1A4 PMAFU Prescription medication A frequency units Prescription medication A frequency units Column Positions 89 1 = daily 2 = weekly 3 = monthly Blank if #1A5, PMAP = 1 (Yes). 1A5 PMAP Prescription medication A PRN medicine Prescription medication A Prescribed as PRN? Column Positions 91 0 = No 1 = Yes NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 53
56 1A6 PMAPF Form A4: Subject Medications Prescription medication A PRN frequency Prescription medication A PRN frequency (average for the past 2 weeks): total number of doses taken per day, week or month. Length of Field 2 Column Positions > 0 to 99 Blank if #1A5, PMAP = 0 (No). 1A7 PMAPFU Prescription medication A PRN frequency units Prescription medication A PRN frequency units Column Positions 96 1 = daily 2 = weekly 3 = montly Blank if #1A5, PMAP = 0 (No). 1B PMB Prescription medication B name Prescription medication B name Length of Field 30 Column Positions Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 54
57 Length of Field 5 1B1 PMBS Column Positions Form A4: Subject Medications Prescription medication B strength Prescription medication B strength > 0.00 to (decimals allowed) 1B2 Column Positions 135 PMBSU Prescription medication B strength units Prescription medication B strength units 1 = µg 2 = mg 3 = ml 4 = IU 1B3 PMBF Prescription medication B frequency Prescription medication B frequency: total number of doses per day, week or month Length of Field 2 Column Positions > 0 to 99 Blank if #1B5, PMBP = 1 (Yes). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 55
58 1B4 Column Positions 140 PMBFU Form A4: Subject Medications Prescription medication B frequency units Prescription medication B frequency units 1 = daily 2 = weekly 3 = monthly Blank if #1B5, PMBP = 1 (Yes). 1B5 PMBP Column Positions 142 Prescription medication B PRN medicine Prescription medication B Prescribed as PRN? 0 = No 1 = Yes 1B6 PMBPF Prescription medication B PRN frequency Prescription medication B PRN frequency (average for the past 2 weeks): total number of doses taken per day, week or month. Length of Field 2 Column Positions > 0 to 99 Blank if #1B5, PMBP = 0 (No). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 56
59 1B7 Column Positions 147 PMBPFU Form A4: Subject Medications Prescription medication B PRN frequency units Prescription medication B PRN frequency units 1 = daily 2 = weekly 3 = monthly Blank if #1B5, PMBP = 0 (No). 1C PMC Length of Field 30 Column Positions Prescription medication C name Prescription medication C name Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). 1C1 PMCS Prescription medication C strength Prescription medication C strength Length of Field 5 Column Positions > 0.00 to (decimals allowed) NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 57
60 1C2 Column Positions 186 PMCSU Form A4: Subject Medications Prescription medication C strength units Prescription medication C strength units 1 = µg 2 = mg 3 = ml 4 = IU 1C3 PMCF Prescription medication C frequency Prescription medication C frequency: total number of doses per day, week or month Length of Field 2 Column Positions > 0 to 99 Blank if #1C5, PMCP = 1 (Yes). 1C4 PMCFU Prescription medication C frequency units Prescription medication C frequency units Column Positions = daily 2 = weekly 3 = monthly Blank if #1C5, PMCP = 1 (Yes). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 58
61 1C5 PMCP Column Positions 193 Comment Form A4: Subject Medications Prescription medication C PRN medicine Prescription medication C Prescribed as PRN? 0 = No 1 = Yes 1C6 PMCPF Prescription medication C PRN frequency Prescription medication C PRN frequency (average for the past 2 weeks): total number of doses taken per day, week or month. Length of Field 2 Column Positions > 0 to 99 Blank if #1C5, PMCP = 0 (No). 1C7 PMCPFU Prescription medication C PRN frequency units Prescription medication C PRN frequency units Column Positions = daily 2 = weekly 3 = monthly Blank if #1C5, PMCP = 0 (No). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 59
62 1D PMD Length of Field 30 Column Positions Form A4: Subject Medications Prescription medication D name Prescription medication D name Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). 1D1 PMDS Prescription medication D strength Prescription medication D strength Length of Field 5 Column Positions > 0.00 to (decimals allowed) 1D2 PMDSU Prescription medication D strength units Prescription medication D strength units Column Positions = µg 2 = mg 3 = ml 4 = IU NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 60
63 1D3 PMDF Form A4: Subject Medications Prescription medication D frequency Prescription medication D frequency: total number of doses per day, week or month Length of Field 2 Column Positions > 0 to 99 Blank if #1D5, PMDP = 1 (Yes). 1D4 PMDFU Prescription medication D frequency units Prescription medication D frequency units Column Positions = daily 2 = weekly 3 = monthly Blank if #1D5, PMDP = 1 (Yes). 1D5 PMDP Prescription medication D PRN medicine Prescription medication D Prescribed as PRN? Column Positions = No 1 = Yes NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 61
64 1D6 PMDPF Form A4: Subject Medications Prescription medication D PRN frequency Prescription medication D PRN frequency (average for the past 2 weeks): total number of doses taken per day, week or month. Length of Field 2 Column Positions > 0 to 99 Blank if #1D5, PMDP = 0 (No). 1D7 PMDPFU Prescription medication D PRN frequency units Prescription medication D PRN frequency units Column Positions = daily 2 = weekly 3 = monthly Blank if #1D5, PMDP = 0 (No). 1E PME Prescription medication E name Prescription medication E name Length of Field 30 Column Positions Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 62
65 Length of Field 5 1E1 PMES Column Positions Form A4: Subject Medications Prescription medication E strength Prescription medication E strength > 0.00 to (decimals allowed) 1E2 Column Positions 288 PMESU Prescription medication E strength units Prescription medication E strength units 1 = µg 2 = mg 3 = ml 4 = IU 1E3 PMEF Prescription medication E frequency Prescription medication E frequency: total number of doses per day, week or month Length of Field 2 Column Positions > 0 to 99 Blank if #1E5, PMEP = 1 (Yes). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 63
66 1E4 Column Positions 293 PMEFU Form A4: Subject Medications Prescription medication E frequency units Prescription medication E frequency units 1 = daily 2 = weekly 3 = monthly Blank if #1E5, PMEP = 1 (Yes). 1E5 PMEP Column Positions 295 Prescription medication E PRN medicine Prescription medication E Prescribed as PRN? 0 = No 1 = Yes 1E6 PMEPF Prescription medication E PRN frequency Prescription medication E PRN frequency (average for the past 2 weeks): total number of doses taken per day, week or month. Length of Field 2 Column Positions > 0 to 99 Blank if #1E5, PMEP = 0 (No). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 64
67 1E7 Column Positions 300 PMEPFU Form A4: Subject Medications Prescription medication E PRN frequency units Prescription medication E PRN frequency units 1 = daily 2 = weekly 3 = monthly Blank if #1E5, PMEP = 0 (No). 1F PMF Length of Field 30 Column Positions Prescription medication F name Prescription medication F name Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). 1F1 PMFS Prescription medication F strength Prescription medication F strength Length of Field 5 Column Positions > 0.00 to (decimals allowed) NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 65
68 1F2 Column Positions 339 PMFSU Form A4: Subject Medications Prescription medication F strength units Prescription medication F strength units 1 = µg 2 = mg 3 = ml 4 = IU 1F3 PMFF Prescription medication F frequency Prescription medication F frequency: total number of doses per day, week or month Length of Field 2 Column Positions > 0 to 99 Blank if #1F5, PMFP = 1 (Yes). 1F4 PMFFU Prescription medication A frequency units Prescription medication A frequency units Column Positions = daily 2 = weekly 3 = monthly Blank if #1F5, PMFP = 1 (Yes). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 66
69 1F5 PMFP Column Positions 346 Form A4: Subject Medications Prescription medication F PRN medicine Prescription medication F Prescribed as PRN? 0 = No 1 = Yes 1F6 PMFPF Prescription medication F PRN frequency Prescription medication F PRN frequency (average for the past 2 weeks): total number of doses taken per day, week or month. Length of Field 2 Column Positions > 0 to 99 Blank if #1F5, PMFP = 0 (No). 1F7 PMFPFU Prescription medication F PRN frequency units Prescription medication F PRN frequency units Column Positions = daily 2 = weekly 3 = monthly Blank if #1F5, PMFP = 0 (No). NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 67
70 1G Length of Field 30 PMG Column Positions Form A4: Subject Medications Prescription medication G name Prescription medication G name Character Any text or numbers but cannot use single quotes ( ), double quotes ( ), ampersands (&), or percentage signs (%). 1G1 PMGS Prescription medication G strength Prescription medication G strength Length of Field 5 Column Positions > 0.00 to (decimals allowed) 1G2 PMGSU Prescription medication G strength units Prescription medication G strength units Column Positions = µg 2 = mg 3 = ml 4 = IU NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 68
71 1G3 PMGF Form A4: Subject Medications Prescription medication G frequency Prescription medication G frequency: total number of doses per day, week or month Length of Field 2 Column Positions > 0 to 99 Blank if #1G5, PMGP = 1 (Yes). 1G4 PMGFU Prescription medication G frequency units Prescription medication G frequency units Column Positions = daily 2 = weekly 3 = monthly Blank if #1G5, PMGP = 1 (Yes). 1G5 PMGP Prescription medication G PRN medicine Prescription medication G Prescribed as PRN? Column Positions = No 1 = Yes NACC UDS Initial Visit Packet (version 1.2, March 2006) Data Element Dictionary - 69
NACC Uniform Data Set (UDS) DATA ELEMENT DICTIONARY for Follow-up Visit Packet (FVP)
Department of Epidemiology, School of Public Health and Community Medicine, University of Washington 4311 11 th Avenue NE #300 Seattle, WA 98105 phone: (206) 543-8637; fax: (206) 616-5927 e-mail: naccmail@u.washington.edu
NACC Uniform Data Set (UDS) DATA ELEMENT DICTIONARY for Telephone Follow-up Packet (TFP)
Department of Epidemiology, School of Public Health, University of Washington 4311 11 th Avenue NE #300 Seattle, WA 98105 phone: (206) 543-8637; fax: (206) 616-5927 e-mail: naccmail@u.washington.edu website:
Version 3.0, March 2015
NACC Uniform Set Element Dictionary For Initial Visit Visit Packet sion 3.0, March 2015 Copyright 2006, 2008, 2015, 2017 University of Washington. Created and published by the ADC Clinical Task Force (John
Version 3.0, March 2015
NACC Uniform Set Element Dictionary For the Milestones Form sion 3.0, March 2015 Copyright 2015 University of Washington. Created and published by the ADC Clinical Task Force (John C. Morris, MD, Chair)
NACC Minimum Data Set (MDS) Data Element Dictionary
Department of Epidemiology, School of Public Health, University of Washington 4311 11th Avenue NE #300 Seattle, WA 98105 phone: (206) 543-8637; fax: (206) 616-5927 e-mail: naccmail@u.washington.edu website:
NACC Minimum Data Set (MDS) Public Data Element Dictionary
Department of Epidemiology, School of Public Health and Community Medicine, University of Washington 4311 11 th Avenue NE #300 Seattle, WA 98105 phone: (206) 543-8637; fax: (206) 616-5927 e-mail: naccmail@u.washington.edu
WELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
Overview of the PPMI Widespread Recruitment Initiative. Tatiana Foroud Indiana University Genetic Coordination Center (GCC)
Overview of the PPMI Widespread Recruitment Initiative Tatiana Foroud Indiana University Genetic Coordination Center (GCC) G-PPMI: Widespread Recruitment MJFF and the Genetic Coordination Core (GCC) developed
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM Dr. Mr. Mrs. Ms. Miss New Patient or Returning Patient FULL LEGAL NAME: Reason for today s visit: Mohs Excision Skin Check other:
Federation of State Boards of Physical Therapy Minimum Data Set Questionnaire
Federation of State Boards of Physical Therapy Minimum Data Set Questionnaire Purpose: Understanding the current United States Health Workforce enables Federal and State Governments and Health Professional
2016 Pharmacist Re-Licensure Survey Instrument
1. Sex a. Male b. Female 2016 Pharmacist Re-Licensure Survey Instrument 2. Ethnicity: Are you Hispanic or Latino? a. Yes b. No 3. Race (Check all that apply.) a. American Indian or Alaska Native b. Black
Alcohol use and binge drinking among Hispanic/Latino subculture youth, and the differences in the affect of acculturation
Alcohol use and binge drinking among Hispanic/Latino subculture youth, and the differences in the affect of acculturation Hal Johnson, MPH Florida Substance Abuse Program Office and the FSU Florida Center
RSR Crosswalk. Variable Client Race Race ID Values White 1 Black 2 Asian 3 Hawaiian / PI 4 Native American (AK native) 5
October 2017 Purpose RSR Crosswalk This document can help you compare the data you currently collect in your data management system to the data required in the Ryan White Services Report (RSR). The Crosswalk
WELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
Personal Information. Full Name: Address: Primary Phone: Yes No Provider Yes No. Alternate Phone: Yes No Provider Yes No
OFFICE USE ONLY: Date of Intake: ID#: Staff mbr: Personal Information Full Name: Address: _ Last First M.I. Street Address Apartment/Unit # City State Zip Code County Date of Birth: Age: Mobile phone?
Cover Sheet for Example Documentation
Cover Sheet for Example Documentation Please complete the following form and submit along with your documentation. If you have any questions, please email us at accreditation@astho.org. The following documentation
Cirrhosis and Liver Cancer Mortality in the United States : An Observational Study Supplementary Material
Cirrhosis and Liver Cancer Mortality in the United States 1999-2016: An Observational Study Supplementary Material Elliot B. Tapper MD (1,2) and Neehar D Parikh MD MS (1,2) 1. Division of Gastroenterology
Alzheimer Disease Research Center
UPMC Montefiore, 4 West 200 Lothrop Street Pittsburgh, PA 15213-2582 412-692-2700 Fax: 412-692-2710 Dear Friends: Thank you for your inquiry about the (ADRC). Attached is an application which asks for
Chapter Two Incidence & prevalence
Chapter Two Incidence & prevalence Science is the observation of things possible, whether present or past. Prescience is the knowledge of things which may come to pass, though but slowly. LEONARDO da Vinci
CHRONOLOGICAL RECORD OF MEDICAL CARE Behavioral Medicine Associates, Inc North Virginia Avenue Roswell, NM 88201
CHRONOLOGICAL RECORD OF MEDICAL CARE Behavioral Medicine Associates, Inc. 1010 North Virginia Avenue Roswell, NM 88201 Instructions: Please fill this form out completely. All items must be responded to.
Evaluation of Grief Support Services Survey. Elective Modules and Questions
Evaluation of Grief Support Services Survey Elective Modules and Questions HOW TO USE THE EGSS SURVEY ELECTIVE MODULES AND QUESTIONS 1. Bereavement Component Modules The following modules represent various
o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological
Adult New Patient Registration PATIENT DOB: / / MONTH DAY YEAR PATIENT NAME: LAST FIRST MI o Abnormal Heartbeat Patient Medical History: Please mark all that apply o Chronic Headaches o Hepatitis C o Neuropathy
Next, I m going to ask you to read several statements. After you read each statement, circle the number that best represents how you feel.
Participant ID: Interviewer: Date: / / The [clinic name], Devers Eye Institute, and the Northwest Portland Area Indian Health Board are doing a survey about beliefs and behaviors related to eye health
THE EMERGE SURVEY ON TAKING PART IN BIOBANK RESEARCH: VERSION A
THE EMERGE SURVEY ON TAKING PART IN BIOBANK RESEARCH: VERSION A What is this survey about? This survey is about your views on taking part in medical research. We want to understand what you think about
Screening Summary (SS2)
15Screening SummarySS217 Aug 06 Depression in Alzheimer s Disease Study - 2 DIADS-2 Screening Summary (SS2) Keyed: ( ) Purpose: Document findings about eligibility for DIADS-2 and about medical and social
Survey for Healthcare Providers and Paid Caregivers
Survey for Healthcare Providers and Paid Caregivers We need your help. Your ideas and experience in providing care for persons with Alzheimer's disease and related dementias will help inform the creation
Survey for Concerned Family and Friends
Survey for Concerned Family and Friends We need your help. Your ideas and experiences with persons with Alzheimer's disease and related dementias will help inform the creation of a Florida state plan to
select class BEST VALUE! $85 $90 $55 $60 $40 $45
Tomahawk Strong Bones Participant Registration Form Mondays and Thursdays January 9 May 25, 2017 Location: United Methodist Church (1104 School Rd, Tomahawk, WI 54487) Our Strong Bones Program follows
Health Professions Data Series: Dental Hygienist 2017
Health Professions Data Series: Dental Hygienist 2017 1. Zip Code of Primary Residence Section 1: Demographics 2. Sex Male Female Decline to Answer 3. Year of Birth 4. Are you Hispanic/Latino/Spanish?
ADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):
ADULT PATIENT HISTORY FORM DEMOGRAPHIC INFORMATION: Name: Address: City: State: Zip: Age: Date of Birth: Gender: Male Female Transgender Marital Status: Never Married Domestic Partners Married Separated
The 2004 National Child Count of Children and Youth who are Deaf-Blind
The 2004 National Child Count of Children and Youth who are Deaf-Blind NTAC The Teaching Research Institute Western Oregon University The Helen Keller National Center Sands Point, New York The National
National Institute on Aging
National Institute on Aging Recruitment and Retention Outreach to Minority and Health Disparity Populations: Phillips & Flatheads: Can a toolbox be far behind? J Taylor Harden, Ph.D., R.N. F.A.A.N., F.G.S.A.
2003 National Immunization Survey Public-Use Data File
SECTION 1. ID, WEIGHT AND FLAG VARIABLES Section 1 Variable Name SEQNUMC Label UNIQUE CHILD IDENTIFIER Frequency of Missing/Non-missing Values All Data 30930 21310 NON-MISSING CHARACTER STRING 000011 MINIMUM
We (will) Ask Everyone*
SBIRT@Wishard We (will) Ask Everyone* Indiana and Wishard Health received $8.3 Million to improve early substance use detection and intervention. Goal: Screen every primary care patient over the age of
PATIENT INFORMATION. (Last) (First) (Middle) (Last) (City) (State) (Zip)
PATIENT INFMATION : Address: (Last) (First) (Middle) (Last) (City) (State) (Zip) Home Phone: Cell Phone: Email address: Birth date: : Gender: When is the best time to contact you? May we email you for
Hepatitis Case Investigation
* indicates required fields Does patient also have: Hepatitis Case Investigation West Virginia Electronic Disease Surveillance System Division of Surveillance and Disease Control Infectious Disease Epidemiology
UDS version 3 Summary of major changes to UDS form packets
UDS version 3 Summary of major changes to UDS form packets from version 2 to VERSION 3 february 18 final Form A1: Subject demographics Updated question on principal referral source to add additional options
Case Number: (For Office Use Only) Social Security #: - - Birthday: - - Social Security#: - - Birthday: - - How did you hear about us?
Date: Name: Case Number: (For Office Use Only) Nickname: Address: City: State: Zip: Social Security #: - - Birthday: - - Spouse s Name: Social Security#: - - Birthday: - - Contact Information Home: - -
Name: Phone #: Address: Cell Phone #: Address: I d like to participate in:
Strong Women and Strong Women Advance Program 12-Week Participant Registration Form January 8-April 2*, 2018 *Good Friday Week Schedule Changes: Strong Classes class will meet Monday (3/26) instead of
NEW PATIENT HEALTH HISTORY
Meeks and Zilberfarb Orthopedics 1101 Beacon Street. Brookline, MA 02246 40 Allied Drive, Dedham, MA 02026 Tel: 617-232-2663 Fax: 617-232-6342 Tel:781-326-1561 Fax:781-326-1562 Jeffrey L. Zilberfarb, MD
Strategic Peer-Enhanced Care and Treatment Retention Model (SPECTRuM) Initiative. Intervention Protocol #2
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH BUREAU OF INFECTIOUS DISEASE AND LABORATORY SCIENCES HIV/AIDS AND STD SURVEILLANCE PROGRAM AND OFFICE OF HIV/AIDS Strategic Peer-Enhanced Care and Treatment Retention
Demographics and Health Data
Demographics and Health Data Information for Local Planners City of Puyallup, WA Demographic Characteristics Environmental Health Division 3629 South D Street, Tacoma, WA 98418 (253) 798-6470 Table 1 presents
NACC Uniform Data Set (UDS) FORMS for Initial Visit Packet
Department of Epidemiology, School of Public Health, University of Washington 4311 11 th Avenue NE #300 Seattle, WA 98105 phone: (206) 543-8637; fax: (206) 616-5927 e-mail: naccmail@u.washington.edu website:
Name: Date of Birth: Address: City: State: Zip Code: Phone Number: Cell Phone: Work Number: Race: Primary Language: Secondary Language:
Address: Phone Number: Cell Phone: Work Number: Email: Last 4 of SS #: Patient Demographic Information: Gender: Male Female Marital Status Single Married Widowed Divorced Other: Ethnicity Hispanic or Latino
AAll s well that ends well; still the fine s the crown; Whate er the course, the end is the renown. WILLIAM SHAKESPEARE, All s Well That Ends Well
AAll s well that ends well; still the fine s the crown; Whate er the course, the end is the renown. WILLIAM SHAKESPEARE, All s Well That Ends Well mthree TrEATMENT MODALITIES 7 ž 21 ATLAS OF ESRD IN THE
Demographics and Health Data
Demographics and Health Data Information for Local Planners City of Lakewood, WA Demographic Characteristics Environmental Health Division 3629 South D Street, Tacoma, WA 98418 (253) 798-6470 Table 1 presents
Milk Taste Test. Prepared by Shelley Kuklish Epidemiologist. September 2008
Milk Taste Test 2008 Prepared by Shelley Kuklish Epidemiologist September 2008 Table of Contents Executive Summary..3 Introduction...6 Methods.. 6 Results. 7 Conclusions.. 12 2 Executive Summary The purpose
July 2019 Submission Formatting Information
July 2019 Submission Formatting Information General Formatting Information for Data Files All data files must be in standard ASCII comma-delimited format, either CSV or text format. Each line must be terminated
POMP Home-Delivered Meals
POMP Home-Delivered Meals (Version: April 1, 2011) Now we are going to talk about home-delivered meals you receive from (Agency/Provider Name). HDM1. When was the last time you received a home-delivered
List of Detailed Tables
This announcement signals the release of the 2011 Mortality Multiple Cause Micro-data Files. The file can be accessed at: http://www.cdc.gov/nchs/data_access/vitalstatsonline.htm This document contains
THE AP-GfK POLL. Conducted by GfK Roper Public Affairs & Media
GfK Custom Research North America THE AP-GfK POLL Conducted by GfK Roper Public Affairs & Media Interview dates: July 16-July 20, 2009 Interviews: 1,006 adults Margin of error: +/- 3.1 percentage points
UCLA Alzheimer s and Dementia Care Program. 200 UCLA Medical Plaza, Suite 365A Los Angeles, CA
UNIVERSITY OF CALIFORNIA, LOS ANGELES UCLA BERKELEY DAVIS IRVINE LOS ANGELES MERCED RIVERSIDE SAN DIEGO SAN FRANCISCO SANTA BARBARA SANTA CRUZ Alzheimer s and Dementia Care Program 200 UCLA Medical Plaza,
Gender: Male Female Age: Current Address: City: State: Zip Code: Work Phone: Is it okay to leave a message? VISIT INFORMATION
SIENA PROACTIVE INTERNAL MEDICINE DR. DEBORAH BLENNER 45 Terry Road, Suite B Smithtown, NY 11787 www.sienaproactive.com Phone: (631) 656-8171 Fax: (631) 656-8173 PATIENT INFORMATION Last Name: First Name:
Choice Counseling Associates
Amy Vitacolonna, MS, LMHCA, RT/CT 719 Sleater-Kinney Rd SE, Suite 212 Lacey, WA 98503 (360) 349-8775 (office) (360) 584-9048 (fax) ChoiceCounselingAssociates@gmail.com ChoiceCounselingAssociates.com Choice
Results from the 2013 NAQC Annual Survey of Quitlines
Results from the 2013 NAQC Annual Survey of Quitlines Prepared by: Maria Rudie and Linda Bailey February 2015 Background of Annual Survey Conducted Annually 2004-2006, 2008-2013 Research Partners: 2013
CASE HISTORY (ADULT) Date form completed:
Mailing Address: TCU Box 297450 Fort Worth, TX 76129 MILLER SPEECH AND HEARING CLINIC TEXAS CHRISTIAN UNIVERSITY Street Address: 3305 W. Cantey Fort Worth, TX 76129 CASE HISTORY (ADULT) Date form completed:
Food Labeling Survey ~ January 2019
Food Labeling Survey ~ January 2019 1 Introduction Research Objective Understand consumer attitudes towards healthy labels and different food packaging aspects that drive purchase behavior. Sampling Research
School Consultation Project Application
2018-2019 School Consultation Project Application The goal of the School Consultation Project is to help your school district increase its capacity to service students with autism spectrum disorders (ASD)
ELIMINATING HEALTH DISPARITIES IN AN URBAN AREA. VIRGINIA A. CAINE, M.D., DIRECTOR MARION COUNTY HEALTH DEPARTMENT INDIANAPOLIS, INDIANA May 1, 2002
ELIMINATING HEALTH DISPARITIES IN AN URBAN AREA VIRGINIA A. CAINE, M.D., DIRECTOR MARION COUNTY HEALTH DEPARTMENT INDIANAPOLIS, INDIANA May 1, 2002 Racial and ethnic disparities in health care are unacceptable
Fertility Specialty Care
Fertility Specialty Care PATIENT INFORMATION: Last Name First Name & Initial Address City State Zip Home Phone ( ) Cell Phone ( ) Date of Birth Social Security Number Marital Status: Married Single Ethnicity:
Location of RSR Client-level Data Elements in CAREWare Updated Sept 2017
Location of RSR Client-level Data Elements in CAREWare Updated Sept 2017 Demographics Required of all clients that received any core medical or support service if they are ELIGIBLE for RWHAP services.
National Deaf Center on Postsecondary Outcomes. Data Interpretation Guide for State Reports: FAQ
National Deaf Center on Postsecondary Outcomes Data Interpretation Guide for State Reports: FAQ This document was developed under a grant from the U.S. Department of Education, OSEP #HD326D160001. However,
STATE OF ARKANSAS OFFICE OF STATE PROCUREMENT 1509 West 7th Street, Room 300 Little Rock, Arkansas BID RESPONSE PACKET
STATE OF ARKANSAS OFFICE OF STATE PROCUREMENT 1509 West 7th Street, Room 300 Little Rock, Arkansas 72201-4222 BID RESPONSE PACKET SP-16-0217 CAUTION TO VENDOR Vendor s failure to submit items and/or information
Cancer Genetics Baylor All Saints Medical Center at Fort Worth
Cancer Genetics Baylor All Saints Medical Center at Fort Worth Thank you for your interest in the Hereditary Cancer Risk Program (HCRP). Please complete the family history and risk factor questionnaire
Vision/Lifestyle Questionnaire
Roger J. Meyer, M.D. Retina Fellowship Trained Macular Degeneration Diabetic Eye Care Glaucoma Robert M. Reinauer, M.D. Retina Fellowship Trained Surgical/Medical Treatment of the Retina & Vitreous Macular
Dear Family or Referral:
Dear Family or Referral: APPLICATION for: South Carolina School for the Deaf and the Blind 355 Cedar Springs Road, Spartanburg SC 29302 Phone: (864) 577-7540 Toll Free: (888) 447-2732 Fax: (864) 577-7561
Assistant Superintendent of Business &
THE LAMPHERE SCHOOLS ADMINISTRATION CENTER 3121 Dorchester Madison Heights, Michigan 4871-199 Telephone: (248) 589-199 FAX: (248) 589-2618 DALE STEEN Superintendent Finance PATRICK DILLON Assistant Superintendent
NCDB The National Center on Deaf-Blindness
The 2016 National Child Count of Children and Youth who are Deaf-Blind NCDB The National Center on Deaf-Blindness October 2017 Table of Contents The 2016 National Child Count of Children and Youth who
LUCAS CHIROPRACTIC 903 Howard St. Walla Walla WA PATIENT INTAKE - update
LUCAS CHIROPRACTIC 903 Howard St. Walla Walla WA 99362 PATIENT INTAKE - update Name Today s Date / / Date of Birth / / Address City State Zip Please check box for preferred communication means E-Mail Home
Survey of Dentists in Delaware
Survey of Dentists in Delaware To determine the current capacity and needs of dentists in Delaware to address the oral health needs of Delawareans with Complete the questions on the pages that follow and
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC 28470 Patient Demographic Information Account # Last Name: SSN: / / First: Middle: Marital Status: Single Married Separated Nickname:
Has your child ever received a speech and language evaluation? if so, when? Has he/she attended therapy?
Today s Date: Cleft Palate and Craniofacial Speech Disorders - Intake Form Welcome to Momentum Therapy Center. The information you provide on this form will help us prepare your child s upcoming speech-language
CIT-06 Eligibility Questionnaire
Today s Date: Last Name: First Name: Middle Name: Date of Birth: Height: Weight (lbs): PERSONAL CONTACT INFORMATION Street Address: City: State: Zip code: Home Phone: Cell Phone: Work Phone: Email Address:
July 2018 Submission Formatting Information
July 2018 Submission Formatting Information General Formatting Information for Export Files All data export files must be in standard ASCII comma-delimited format, either CSV or text format. Each line
Registration Form Women s Health Initiative
YWCA WHI 1500 14 th St. Lubbock, Texas 79401 Phone: (806) 687-8858 Fax: (806) 784-0698 1 Registration Form Women s Health Initiative Date: Name (Last, First, middle, Maiden) Age: Date of Birth SS # Mailing
Geographical Accuracy of Cell Phone Samples and the Effect on Telephone Survey Bias, Variance, and Cost
Geographical Accuracy of Cell Phone Samples and the Effect on Telephone Survey Bias, Variance, and Cost Abstract Benjamin Skalland, NORC at the University of Chicago Meena Khare, National Center for Health
Physical Issues: Emotional Issues: Legal Issues:
Men s Facility 1119 Ferry Street Lafayette, IN 47901 Phone: (765) 807-0009 Fax: (765) 807-0030 Hope Apartments 920 N 11th St. Lafayette, IN 47904 Phone: (765) 742-3246 Fax: (765) 269-9110 APPLICATION FOR
Cancer Risk Assessment Questionnaire
Information about your health, lifestyle, and family history will help us determine your risk for cancer. If you already have cancer, it can help us determine the chance your cancer was caused by an inherited
Suicide Prevention Gatekeeper Training Results (2009)
Suicide Prevention Gatekeeper Training Results (2009) The Ohio State University Campus Suicide Prevention Program suicideprevention.osu.edu Mission: To develop a comprehensive, effective, culturally responsive,
MDS Intake Questions July 21, 2009
MDS Intake Questions July 21, 2009 Notes: The updated MDS Intake questions contain two options for assessing use of different tobacco types. The first (Option 1), which is included in the primary section
CHEMICAL DEPENDENCY CLINIC
CHEMICAL DEPENDENCY CLINIC 100 HIGHLANDS BLVD SUITE 101 PORT JEFFERSON NEW YORK 11777 631-331-8200 FAX 631-331-8259 Name: DOB: Address: City: Zip Code: Phone Numbers: Home: ( ) Can we call you at Home?
Home and Community Based Services (HCBS)
To Whom It May Concern: To be considered for membership, the following must be submitted: 1. A Fountain House Membership Application and supplementary substance abuse questionnaire (included at the end
BAYLOR SCOTT & WHITE HEALTH GENETICS QUESTIONNAIRE PATIENT INFORMATION
PATIENT INFORMATION Name: Address: (Last) (First) (Middle) (Street) (City) (State) (Zip) Home Phone: Cell Phone: Email Address: Birth Date: Age: When is the best time to contact you? May we email you for
2012 Medicaid and Partnership Chart
2012 Medicaid and Chart or Alabama $525,000.00 $4,800.00 Minimum: 25,000.00 Alaska $525,000.00 Depends on area of state; Minimum: $113,640 $10,000 in Anchorage $1,656 Minimum:$1838.75 Maximum:$2,841 Minimum:
Women s health status is one of the strongest determinants of how women use the health care system. The
Women s health status is one of the strongest determinants of how women use the health care system. The poorer their health, the more women need and benefit from high-quality, appropriate care. Overall,
Heartland Kidney Network Network Patient Representative (NPR) Application
920 Main Street, Suite 801 Kansas City, MO 64105 Main Telephone Number: 816/880-9990 Patient Only Toll-Free Telephone Number: 800/444-9965 Fax: 816/880-9088 Heartland Kidney Network Network Patient Representative
New Hampshire Continua of Care. PATH Street Outreach Program Entry Form for HMIS
Please refer to the 2014 HUD HMIS Data Standards Version 5.1, available on the NH-HMIS website: www.nh-hmis.org for an explanation of the data elements in this form. Date form completed: Outreach worker
First Name Middle Name Last Name Name You Prefer Date
Supportive Housing for Homeless Women & Families Application for Residency First Fruit Ministries 2750 Vance Street Wilmington, NC 28412 Phone 910.794.9656 Fax 910.794.9657 First Name Middle Name Last
Form A3: Subject Family History
Initial Visit Packet NACC Uniform Data Set (UDS) Form A: Subject Family History ADC name: Subject ID: Form date: / / Visit #: Examiner s initials: INSTRUCTIONS: This form is to be completed by a clinician
NORC AmeriSpeak Omnibus Survey: 41% of Americans Do Not Intend to Get a Flu Shot this Season
Omnibus Survey: 41% of Americans Do Intend to Get a Flu Shot this Season Interview Dates: November 14-19, 2018 Nationally representative sample of 1,202 English-speaking adults age 18 and over, conducted
Notto Chiropractic Health Center Patient Information
Notto Chiropractic Health Center Patient Information Acct #: Name: Preferred Name: Address: City: State: Zip: Home Phone: ( ) - _. Work Phone: ( ) -. Who Referred You? In Case of Emergency: Phone Number:
NCQA did not add new measures to Accreditation 2017 scoring.
2017 Accreditation Benchmarks and Thresholds 1 TO: Interested Organizations FROM: Patrick Dahill, Assistant Vice President, Policy DATE: August 2, 2017 RE: 2017 Accreditation Benchmarks and Thresholds
ARTHRITIS AND ORTHOPEDIC MEDICAL CLINIC
Name: DOB/Age: Height: Weight: Today s Date: PRESENT ILLNESS: What medical problem brings you to the office? Is this problem related to an injury? When? Work Related? What treatments have you received?
ACEP National H1N1 Preparedness Survey Results
1) On a scale from 1 to 10 (10 being totally prepared and 1 being totally unprepared), do you think your hospital is prepared to manage a surge of H1N1 flu patients this fall and winter? (totally prepared)
Figure 4. Psychoactive Medication Quality Assurance Rating Survey (PQRS)
Figure 4. Psychoactive Medication Quality Assurance Rating Survey (PQRS) Person's Full Name Person's Case Number INSTRUCTIONS TO RATER: These guidelines apply to all items unless indicated otherwise. After
B&T Format. New Measures. Better health care. Better choices. Better health.
1100 13th Street NW, Third Floor Washington, DC 20005 phone 202.955.3500 fax 202.955.3599 www.ncqa.org TO: Interested Organizations FROM: Patrick Dahill, Assistant Vice President, Policy DATE: August 13,
Conceptual framework! Definitions of race and ethnicity Census Questions, Genetics! Social Class, migration, language proficiency!
Conceptual framework! Definitions of race and ethnicity Census Questions, Genetics! Social Class, migration, language proficiency! Patient-physician communication! Clinical Research Examples! Options for
States with Authority to Require Nonresident Pharmacies to Report to PMP
States with Authority to Require Nonresident Pharmacies to Report to PMP Research current through May 2016. This project was supported by Grant No. G1599ONDCP03A, awarded by the Office of National Drug
Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory. Definitions Obesity: Body Mass Index (BMI) of 30 or higher.
Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory Definitions Obesity: Body Mass Index (BMI) of 30 or higher. Body Mass Index (BMI): A measure of an adult s weight in relation
Data Report 2016 Indiana Physician Licensure Survey
Data Report 2016 Indiana Physician Licensure Survey May 2016 0 010 0 010 0 0110101010 0110 0 010 011010 010 0 010 0 0110110 0110 0110 0 010 010 0 010 0 01101010 0110 0 010 010 0 010 0 0 PH YS I C IAN 0