EpiDoC data set. W0 EpiReumaPt (CESOP) W0 EpiReumaPt (CESOP)

Similar documents
PATIENT INTAKE FORM Health & Wellness

Dr. Hall New Patient Paperwork Please fill out these forms completely

Public Health and Nutrition in Older Adults. Patricia P. Barry, MD, MPH Merck Institute of Aging & Health and George Washington University

Evolve180 / Ideal Northwest Health Profile

Our office is located at 2030 Drew Street, Clearwater FL, We are on Drew Street, in between N.E Old Coachman Road and Hercules Avenue.

562 KINGWOOD DRIVE KINGWOOD, TX Application Form

Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715

New Patient Intake Form

Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:

REFERRAL GUIDELINES: RHEUMATOLOGY

OLDER ADULTS. Persons 65 or older

Welcome to the Healthplex!

Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /

ADULT INFORMATION SHEET

NEUROSURGERY PATIENT INTAKE FORM

Patient Information Form

Lipid Clinic Name DOB / / Primary Care MD Cardiologist Endocrinologist

For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.

Kelley's Textbook of Rheumatology. 2 Volume Set. Text with Internet Access Code for Premium Consult Edition

GUPTA SPORTS & SPINE CENTER

WILLIAM K MONTGOMERY, MD

Revitalize, Regenerate & Restore Office of Dr. Kashi Rai. Health Coaching Packet

Chronic Disease Management. Mary Rouleau, RN, RD, CDE Condition Management RN The Center

Screening and Referral. Unit: Programming Pilates Matwork

Patient Name Date MR#: FLORIDA ORTHOPAEDIC INSTITUTE. Race: Ethnicity: (Circle one) Hispanic / Not Hispanic

Medications: Prescription and Non-prescription medications, vitamins, home remedies, birth control pills, herbs.

Phillips Brayford Orthopaedics 48 Tunnel Rd, Suite 203 Pottsville PA Phone: Fax: PATIENT INFORMATION

Korean CHRNA (Community Health Resources and Needs Assessment)

Health History. Date. Address. City State Zip. Age Height Weight BMI. Date of birth Male Female. . Are you currently a patient at OHSU?

Salt Lake Orthopaedic Clinic Initial Visit Form

1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:

Your Disease Risk: Relative Risks

PATIENT REGISTRATION

Patient Name: Date of Birth:

MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No

Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form

History of Present Condition

Athens Rheumatology Clinic, LLC Sana Makhdumi, MD

YOU ARE WHAT YOU EAT

Notto Chiropractic Health Center Patient Information

PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT

New Patient Information

Patient Pain and Function Survey

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

Back In Balance Chiropractic, LLC

Vanguard Rheumatology Partners REGISTRATION FORM (Please Print)

NOTICE TO OUR PATIENTS

Denise E. Bruner, M.D. & Associates, P.C.

Case Study #4: Hypertension and Cardiovascular Disease

Samuel A. Joseph, Jr., M.D. In order to be seen by one of our physicians, you must bring the following to your visit:

Last Name: First Name: Address: Apt/Unit #: City: State: Zip: Best Contact Phone Number: Date of Birth: Age: Profession:

HEALTH QUESTIONNAIRE

CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:

Pennsylvania Department of Health 2003 Behavioral Risks of McKean County Adults Page 1

Indian CHRNA (Community Health Resources and Needs Assessment)

Additional details about you What is your ethnic group? Name of next of kin \ Emergency contact

LIST ALL CURRENT MEDICATIONS BELOW INCLUDING INJECTIONS/INFUSION MEDICINES MEDS) Name of Medication Dose How often taken

} The last 50 years has seen a better understanding of the causes and treatments of cancer.

Research Data Available

Molland Spinal Care, LLC 124 Hwy 35 South Red Bank, NJ Phone:

NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:

Pain Interventions 30 Hagen Drive, Suite Culver Rd. Suite 2 Rochester, NY Rochester, NY (Voice) (Fax)

Patient Information. Insurance Information

*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months

Americans Current Views on Smoking 2013: An AARP Bulletin Survey

About diet and arthritis

STATE OF MUSCULOSKELETAL HEALTH Arthritis and other musculoskeletal conditions in numbers

Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ

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

ARTHRITIS & RHEUMATOLOGY OF GA, PC

15 Most-Googled health questions in New York

The National Council for Osteopathic Research, SDC Version 2.0 Page 1

Standardised Data Collection Questionnaire Patient Information Version 2.0 SDC

New Patient Health Information

Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State

Welcome to MedWell. MedWell Health and Wellness Centers. Don t live with PAIN Live WELL MedWell. o Newspaper o Referred by.

New Patient Medical Questionnaire DATE:

Aches and Pains in Rheumatology: Is it Fibromyalgia, Osteoarthritis, or Rheumatoid Disease?

Comorbidities and Workers Compensation

PATIENT INFORMATION SHEET (please print) Patient s Name: Birthdate Age. Address: Soc.Sec.# Employer: Address: Phone: Spouse Name: Occupation:

New Patient Questionnaire

Nutrition Solutions, LLC Cancellation Policies

Patient Name Date of Birth / / Today s Date / /

ILLINOIS BONE AND JOINT INSTITUTE Rheumatology Medical History Form

Welcome to Medina Family Chiropractic and Acupuncture!

NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:

Carriage House Chiropractic and Acupuncture

Chronic disease surveillance in South Australia

Osteoporosis challenges

WELCOME to the Florence Chiropractic and Wellness Center.

Osteoporosis is a huge taboo once you pass a certain age, but it really doesn t have to be that way. Even though it is a serious, irreversible,

Objectives: What is Osteoporosis 10/8/2015. Bone Health/ Osteoporosis: BASICS OF SCREENING, INTERPRETING, AND TREATING

Thanks again, The BodyEvolver team Fitness Technology Partners, LLC bodyevolver.com

311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship

Numbness: o o o o o. Grade your overall pain. Pain Rating Scale Mosby. Worst Possible Pain. No Pain HURTS LITTLE MORE HURTS EVEN MORE

DATE OF BIRTH: MELANOMA INTAKE

Introduction to the Singapore Chinese Health Study (SCHS)

New Patient Questionnaire Pediatric Orthopaedic Surgery

Health Risk Behaviors in the State of Michigan Behavioral Risk Factor Survey. 19th Annual Report

PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER

Transcription:

EpiDoC data set 1. Data collection Start date 19/09/2011 26/03/2013 01/09/2015 End date 20/12/2013 27/07/2015 Face-to-face Clinical Telephonic Data collection interview assessment interviews n 10,661 3,877 7,591 Telephonic interviews 2. Data structure 2.1. Sociodemographic & socioeconomic data Se Date of birth Ethnicity Nationality Place of birth Marital status Education level Years of education Employment status Household income Household composition Number of people <18y in household Number of people >65y in household Region (NUT II) Location District Population size Home & neighborhood characteristics 1

2.2. Health data Anthropometric measures Height (in cm) Weight (in kg) Body Mass Inde (kg/m 2 ) Chronic diseases (self-report) High blood pressure Diabetes High cholesterol level Pulmonary disease Cardiac disease Gastrointestinal disease Neurologic disease Allergies Mental disease Neoplasic disease Thyroid and parathyroid disease Hypogonadism Hyperuricemia Urinary disease Rheumatic disease Rheumatic diseases Rheumatoid arthritis Spondyloarthritis Psoriatic arthritis Osteoarthritis Osteoporosis Gout 2

Polymyalgia rheumatica Systemic lupus erythematosus Fibromyalgia Periarticular diseases Low back pain Inflammatory low back pain Chondrocalcinosis SAPHO Bsehçet's disease Systemic sclerosis Sjögren's syndrome Inflammatory myopathy Undifferentiated connective tissue disease Mied connective tissue disease Juvenile arthritis Other RMD Who diagnosed RMD Rheumatic complaints Medical history Physical eamination Aniety, depression, physical function & quality of life Hospital Aniety and Depression Scale (HADS) Health Assessment Questionnaire (HAQ) Short Form Health Survey (SF-36) European Quality of Life questionnaire (EQ- 5D-3L) 3

Falls & bone fractures Suffered any fall Where the fall happened (home, street, work) Number of falls (home, street, work) Suffered any bone fracture Number of bone fractures Location of bone fracture Health & employment Retired due to disease Retired due to RMD Work absenteeism due to disease Work disabled due to RMD Unemployed due to disease Unemployed due to RMD Number working hours/week Changed employment status (last year) due to RMD 2.3. Health resources consumption Hospitalizations, home care assistance & medical appointments Was hospitalized (last 12 months/since last contact) Reason & duration of hospitalization Home care assistance (last 12 months/since last contact, currently) Who provides & who pays for home care assistance Medical appointments (last 12 months/since last contact) 4

Number private/public medical appointments Private medical appointments with/without insurance Public medical appointments in hospital/health care center Number private/public medical appointments by specialty Health care system (ADSE, subsystems, private insurance) Medications & other treatments Currently takes any medicine Medicine(s) that is currently taking Other treatments (physical and rehabilitation medicine, behavioral therapy, etc.) Alternative treatments (acupuncture, homeopathy, etc.) 2.4. Lifestyle data Smoking habits (current/past smoker, number of cigarettes, smoking duration) Alcohol intake (frequency, number of units) Coffee intake Physical eercise (frequency, type, age when started) Sleep habits (hours/day) Frequency of watching TV Frequency of using computer/videogames/tablets Frequency of using internet Number of meals/day Frequency of soup, vegetables, fruit, meat, fish, milk/diary, water consumption Frequency of olive oil, wine, beans, fat, sugar, consumption 5

Attitudes towards food Food insecurity scale Food acquisition and preparation 2.5. Biobank & imaging data Serum Whole blood DNA Wrist X-Ray Calcaneus X-Ray Hand X-Ray Hip X-Ray Knee X-Ray Lumbar spine X-Ray Thoracic spine X-Ray Cervical spine X-Ray 6