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Protocol - Medical History

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Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

Description:

This protocol is a self- or proxy-administered questionnaire from the American Health Information Management Association (AHIMA) that collects information on whether a respondent has a specific medical issue and if so, the date of onset.

Protocol:

A. Medical History (Check appropriate)

 

[ ] Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive:

Date of Onset

[ ] High Blood Pressure

Date of Onset

   

[ ] Arthritis

 

[ ] Hypoglycemia

 

[ ] Asthma

 

[ ] Jaundice

 

[ ] Bronchitis

 

[ ] Kidney Disease

 

[ ] Cancer

 

[ ] Low Blood Pressure

 

[ ] Chlamydia

 

[ ] Mental Retardation

 

[ ] Diabetes

 

[ ] Pain or Pressure in Chest

 

[ ] Dizziness

 

[ ] Palpitations

 

[ ] Emphysema

 

[ ] Periods of Unconsciousness

 

[ ] Epilepsy

 

[ ] Rheumatic Fever

 

[ ] Eye Problem

 

[ ] Rheumatism

 

[ ] Fainting

 

[ ] Seizures

 

[ ] Frequent or Severe Headaches

 

[ ] Shortness of Breath

 

[ ] Glaucoma

 

[ ] Stomach Liver or Intestinal Problems

 

[ ] Gonorrhea

[ ] Syphilis

 

[ ] Hearing Impairment

 

[ ] Tuberculosis

 

[ ] Heart Condition

[ ] Tumor

 

[ ] Hemodialysis

 

[ ] Thyroid Problems

 

[ ] Herpes

 

[ ] Urinary Tract Infection

 

[ ] High Blood Cholesterol

 

[ ] Other

 

Personnel and Training Required

None

Equipment Needs

None

Requirements

Requirement CategoryRequired
Average time of greater than 15 minutes in an unaffected individualNo
Major equipmentNo
Specialized requirements for biospecimen collectionNo
Specialized trainingNo

Mode of Administration

Self-administered

Life Stage:

Infant, Toddler, Child, Adolescent, Adult, Senior, All Ages, Pregnancy

Specific Instructions:

The Infectious Diseases and Immunity WG recommend that, for older adults, medical records from a participant's physician may be necessary to provide this information.

Rosa's Law, enacted in October 2010, changes references in federal laws and acts from "mental retardation" to "intellectual disability," and references to a "mentally retarded individual" to "an individual with an intellectual disability." The PhenX Working Group notes that this protocol was developed and tested using previously accepted terminology. Replacing this terminology with the newly enacted standard is at the researcher's discretion.

Research Domain Information

Release Date:

November 12, 2010

Definition

This measure is a questionnaire to collect information on a respondent's medical history.

Purpose

This measure can be used to establish a respondent's history of medical issues.

Selection Rationale

The American Health Information Management Association's (AHIMA's) My Personal Health Record (MyPHR) protocol is a national program used by several state health information management associations in community-based settings.

Language

English, Spanish

Standards

StandardNameIDSource
Common Data Elements (CDE)Person Medical History Event Occurrence Date2543596CDE Browser
Logical Observation Identifiers Names and Codes (LOINC)Medical history proto62890-9LOINC

Process and Review

The Expert Review Panel has not reviewed this measure yet.

Source

American Health Information Management Association (AHIMA). My Personal Health Record (MyPHR). Adult PHR Form 2006, Section F.

General References

None

Protocol ID:

161301

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX161301_Palpitations_Date_Of_Onset_DayPX161301012902Palpitations Date of Onset- Day4N/A
PX161301_Palpitations_Date_Of_OnsetYearPX161301012903Palpitations Date of Onset-Year4N/A
PX161301_Periods_Of_UnconsciousnessPX161301013000Periods of Unconsciousness4N/A
PX161301_Unconsciousness_Date_Of_Onset_MonthPX161301013001Periods of Unconsciousness Date of Onset - Month4N/A
PX161301_Unconsciousness_Date_Of_Onset_DayPX161301013002Periods of Unconsciousness Date of Onset - Day4N/A
PX161301_Unconsciousness_Date_Of_Onset_YearPX161301013003Periods of Unconsciousness Date of Onset - Year4N/A
PX161301_Rheumatic_FeverPX161301013100Rheumatic Fever4N/A
PX161301_RheumaticFever_Date_Of_Onset_MonthPX161301013101Rheumatic Fever Date of Onset - Month4N/A
PX161301_RheumaticFever_Date_Of_Onset_DayPX161301013102Rheumatic Fever Date of Onset - Day4N/A
PX161301_RheumaticFever_Date_Of_Onset_YearPX161301013103Rheumatic Fever Date of Onset - Year4N/A
PX161301_RheumatismPX161301013200Rheumatism4N/A
PX161301_Rheumatism_Date_Of_Onset_MonthPX161301013201Rheumatism Date of Onset - Month4N/A
PX161301_Rheumatism_Date_Of_Onset_DayPX161301013202Rheumatism Date of Onset - Day4N/A
PX161301_Rheumatism_Date_Of_Onset_YearPX161301013203Rheumatism Date of Onset - Year4N/A
PX161301_SeizuresPX161301013300Seizures4N/A
PX161301_Seizures_Date_Of_Onset_MonthPX161301013301Seizures Date of Onset - Month4N/A
PX161301_Seizures_Date_Of_Onset_DayPX161301013302Seizures Date of Onset - Day4N/A
PX161301_Seizures_Date_Of_Onset_YearPX161301013303Seizures Date of Onset - Year4N/A
PX161301_Shortness_Of_BreathPX161301013400Shortness of Breath4N/A
PX161301_ShortnessOfBreath_Date_Of_Onset_MonthPX161301013401Shortness of Breath Date of Onset - Month4N/A
PX161301_ShortnessOfBreath_Date_Of_Onset_DayPX161301013402Shortness of Breath Date of Onset - Day4N/A
PX161301_ShortnessOfBreath_Date_Of_Onset_YearPX161301013403Shortness of Breath Date of Onset - Year4N/A
PX161301_Stomach_Liver_ProblemsPX161301013500Stomach or Liver Problems4N/A
PX161301_StomachLiverIntestinal_Date_Of_Onset_MonthPX161301013501Stomach Liver or Intestinal Problems Date of Onset - Month4N/A
PX161301_StomachLiverIntestinal_Date_Of_Onset_DayPX161301013502Stomach Liver or Intestinal Problems Date of Onset - Day4N/A
PX161301_StomachLiverIntestinal_Date_Of_Onset_YearPX161301013503Stomach Liver or Intestinal Problems Date of Onset - Year4N/A
PX161301_SyphilisPX161301013600Syphilis4N/A
PX161301_Syphilis_Date_Of_Onset_MonthPX161301013601Syphilis Date of Onset - Month4N/A
PX161301_Syphilis_Date_Of_Onset_DayPX161301013602Syphilis Date of Onset - Day4N/A
PX161301_PalpitationsPX161301012900Palpitations4N/A
PX161301_Palpitations_Date_Of_Onset_MonthPX161301012901Palpitations Date of Onset- Month4N/A
PX161301_Syphilis_Date_Of_Onset_YearPX161301013603Syphilis Date of Onset - Year4N/A
PX161301_TuberculosisPX161301013700Tuberculosis4N/A
PX161301_Tuberculosis_Date_Of_OnsetMonthPX161301013701Tuberculosis Date of Onset-Month4N/A
PX161301_Tuberculosis_Date_Of_OnsetDayPX161301013702Tuberculosis Date of Onset-Day4N/A
PX161301_Tuberculosis_Date_Of_OnsetYearPX161301013703Tuberculosis Date of Onset-Year4N/A
PX161301_TumorPX161301013800Tumor4N/A
PX161301_Tumor_Date_Of_Onset_MonthPX161301013801Tumor Date of Onset - Month4N/A
PX161301_Tumor_Date_Of_Onset_DayPX161301013802Tumor Date of Onset - Day4N/A
PX161301_Tumor_Date_Of_Onset_YearPX161301013803Tumor Date of Onset - Year4N/A
PX161301_Thyroid_ProblemsPX161301013900Thyroid Problems4N/A
PX161301_Thyroid_Date_Of_Onset_MonthPX161301013901Thyroid Problems Date of Onset - Month4N/A
PX161301_Thyroid_Date_Of_Onset_DayPX161301013902Thyroid Problems Date of Onset - Day4N/A
PX161301_Thyroid_Date_Of_Onset_YearPX161301013903Thyroid Problems Date of Onset - Year4N/A
PX161301_Urinary_Tract_ProblemsPX161301014000Urinary Tract Problems4N/A
PX161301_UrinaryTractInfection_Date_Of_Onset_MonthPX161301014001Urinary Tract Infection Date of Onset - Month4N/A
PX161301_UrinaryTractInfection_Date_Of_Onset_DayPX161301014002Urinary Tract Infection Date of Onset - Day4N/A
PX161301_UrinaryTractInfection_Date_Of_Onset_YearPX161301014003Urinary Tract Infection Date of Onset - Year4N/A
PX161301_OtherPX161301014100Other4N/A
PX161301_Other_SpecifyPX161301014101Other, specify4N/A
PX161301_Other_Date_Of_Onset_MonthPX161301014102Other Date of Onset - Month4N/A
PX161301_Other_Date_Of_Onset_DayPX161301014103Other Date of Onset - Day4N/A
PX161301_AIDSPX161301010200Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive4Variable Mapping
PX161301_AIDS_Date_Of_Onset_MonthPX161301010201Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive Date of Onset - Month4N/A
PX161301_AIDS_Date_Of_Onset_DayPX161301010202Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive Date of Onset - Day4N/A
PX161301_AIDS_Date_Of_Onset_YearPX161301010203Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive Date of Onset -Year4Variable Mapping
PX161301_ArthritisPX161301010300Arthritis4Variable Mapping
PX161301_Arthritis_Date_Of_Onset_MonthPX161301010301Arthritis Date of Onset - Month4N/A
PX161301_Arthritis_Date_Of_Onset_DayPX161301010302Arthritis Date of Onset - Day4N/A
PX161301_Arthritis_Date_Of_Onset_YearPX161301010303Arthritis Date of Onset - Year4Variable Mapping
PX161301_AsthmaPX161301010400Asthma4Variable Mapping
PX161301_Asthma_Date_Of_Onset_MonthPX161301010401Asthma Date of Onset - Month4N/A
PX161301_Asthma_Date_Of_Onset_DayPX161301010402Asthma Date of Onset - Day4N/A
PX161301_Asthma_Date_Of_Onset_YearPX161301010403Asthma Date of Onset - Year4Variable Mapping
PX161301_BronchitisPX161301010500Bronchitis4Variable Mapping
PX161301_Bronchitis_Date_Of_Onset_MonthPX161301010501Bronchitis Date of Onset - Month4N/A
PX161301_Bronchitis_Date_Of_Onset_DayPX161301010502Bronchitis Date of Onset - Day4N/A
PX161301_Bronchitis_Date_Of_Onset_YearPX161301010503Bronchitis Date of Onset - Year4Variable Mapping
PX161301_CancerPX161301010600Cancer4Variable Mapping
PX161301_Cancer_Date_Of_Onset_MonthPX161301010601Cancer Date of Onset - Month4Variable Mapping
PX161301_Cancer_Date_Of_Onset_DayPX161301010602Cancer Date of Onset - Day4N/A
PX161301_Cancer_Date_Of_Onset_YearPX161301010603Cancer Date of Onset - Year4Variable Mapping
PX161301_ChlamydiaPX161301010700Chlamydia4Variable Mapping
PX161301_Chlamydia_Date_Of_Onset_MonthPX161301010701Chlamydia Date of Onset - Month4N/A
PX161301_Chlamydia_Date_Of_Onset_DayPX161301010702Chlamydia Date of Onset - Day4N/A
PX161301_Chlamydia_Date_Of_Onset_YearPX161301010703Chlamydia Date of Onset - Year4N/A
PX161301_DiabetesPX161301010800Diabetes4N/A
PX161301_Diabetes_Date_Of_Onset_MonthPX161301010801Diabetes Date of Onset - Month4N/A
PX161301_Diabetes_Date_Of_Onset_DayPX161301010802Diabetes Date of Onset - Day4N/A
PX161301_Diabetes_Date_Of_Onset_YearPX161301010803Diabetes Date of Onset - Year4N/A
PX161301_DizzinessPX161301010900Dizziness4N/A
PX161301_Dizziness_Date_Of_Onset_MonthPX161301010901Dizziness Date of Onset - Month4N/A
PX161301_Dizziness_Date_Of_Onset_DayPX161301010902Dizziness Date of Onset - Day4N/A
PX161301_Dizziness_Date_Of_Onset_YearPX161301010903Dizziness Date of Onset - Year4N/A
PX161301_EmphysemaPX161301011000Emphysema4N/A
PX161301_Emphysema_Date_Of_Onset_MonthPX161301011001Emphysema Date of Onset - Month4N/A
PX161301_Emphysema_Date_Of_Onset_DayPX161301011002Emphysema Date of Onset - Day4N/A
PX161301_Emphysema_Date_Of_Onset_YearPX161301011003Emphysema Date of Onset - Year4N/A
PX161301_EpilepsyPX161301011100Epilepsy4N/A
PX161301_Epilepsy_Date_Of_Onset_MonthPX161301011101Epilepsy Date of Onset - Month4N/A
PX161301_Epilepsy_Date_Of_Onset_DayPX161301011102Epilepsy Date of Onset - Day4N/A
PX161301_Epilepsy_Date_Of_Onset_YearPX161301011103Epilepsy Date of Onset - Year4N/A
PX161301_Eye_ProblemPX161301011200Eye Problem4N/A
PX161301_Eye_Problem_Date_Of_Onset_MonthPX161301011201Eye Problem Date of Onset - Month4N/A
PX161301_Eye_Problem_Date_Of_Onset_DayPX161301011202Eye Problem Date of Onset - Day4N/A
PX161301_Eye_Problem_Date_Of_Onset_YearPX161301011203Eye Problem Date of Onset - Year4N/A
PX161301_FaintingPX161301011300Fainting4N/A
PX161301_Fainting_Date_Of_Onset_MonthPX161301011301Fainting Date of Onset - Month4N/A
PX161301_Fainting_Date_Of_Onset_DayPX161301011302Fainting Date of Onset - Day4N/A
PX161301_HeadachesPX161301011400Frequent or Severe Headaches4N/A
PX161301_Headaches_Date_Of_Onset_MonthPX161301011401Frequent or Severe Headaches Date of Onset - Month4N/A
PX161301_Headaches_Date_Of_Onset_DayPX161301011402Frequent or Severe Headaches Date of Onset - Day4N/A
PX161301_Headaches_Date_Of_Onset_YearPX161301011403Frequent or Severe Headaches Date of Onset - Year4N/A
PX161301_GlaucomaPX161301011500Glaucoma4N/A
PX161301_Glaucoma_Date_Of_Onset_MonthPX161301011501Glaucoma Date of Onset - Month4N/A
PX161301_Glaucoma_Date_Of_Onset_DayPX161301011502Glaucoma Date of Onset - Day4N/A
PX161301_Glaucoma_Date_Of_Onset_YearPX161301011503Glaucoma Date of Onset -Year4N/A
PX161301_GonorrheaPX161301011600Gonorrhea4N/A
PX161301_Gonorrhea_Date_Of_Onset_MonthPX161301011601Gonorrhea Date of Onset - Month4N/A
PX161301_Gonorrhea_Date_Of_Onset_DayPX161301011602Gonorrhea Date of Onset - Day4N/A
PX161301_Gonorrhea_Date_Of_Onset_YearPX161301011603Gonorrhea Date of Onset - Year4N/A
PX161301_Hearing_ImpairmentPX161301011700Hearing Impairment4N/A
PX161301_HearingImpairment_Date_Of_Onset_MonthPX161301011701Hearing Impairment Date of Onset - Month4N/A
PX161301_HearingImpairment_Date_Of_Onset_DayPX161301011702Hearing Impairment Date of Onset - Day4N/A
PX161301_HearingImpairment_Date_Of_Onset_YearPX161301011703Hearing Impairment Date of Onset - Year4N/A
PX161301_Heart_ConditionPX161301011800Heart Condition4N/A
PX161301_HeartCondition_Date_Of_Onset_MonthPX161301011801Heart Condition Date of Onset - Month4N/A
PX161301_HeartCondition_Date_Of_Onset_DayPX161301011802Heart Condition Date of Onset - Day4N/A
PX161301_HeartCondition_Date_Of_Onset_YearPX161301011803Heart Condition Date of Onset - Year4N/A
PX161301_HemodialysisPX161301011900Hemodialysis4N/A
PX161301_Hemodialysis_Date_Of_Onset_MonthPX161301011901Hemodialysis Date of Onset - Month4N/A
PX161301_Hemodialysis_Date_Of_Onset_DayPX161301011902Hemodialysis Date of Onset - Day4N/A
PX161301_Hemodialysis_Date_Of_Onset_YearPX161301011903Hemodialysis Date of Onset - Year4N/A
PX161301_Fainting_Date_Of_Onset_YearPX161301011303Fainting Date of Onset - Year4N/A
PX161301_HerpesPX161301012000Herpes4N/A
PX161301_Herpes_Date_Of_Onset_MonthPX161301012001Herpes Date of Onset - Month4N/A
PX161301_Herpes_Date_Of_Onset_DayPX161301012002Herpes Date of Onset - Day4N/A
PX161301_Herpes_Date_Of_Onset_YearPX161301012003Herpes Date of Onset - Year4N/A
PX161301_High_Blood_CholesterolPX161301012100High Blood Cholesterol4N/A
PX161301_HighBloodCholesterol_Date_Of_Onset_MonthPX161301012101High Blood Cholesterol Date of Onset - Month4N/A
PX161301_HighBloodCholesterol_Date_Of_Onset_DayPX161301012102High Blood Cholesterol Date of Onset - Day4N/A
PX161301_HighBloodCholesterol_Date_Of_Onset_YearPX161301012103High Blood Cholesterol Date of Onset - Year4N/A
PX161301_High_Blood_PressurePX161301012200High Blood Pressure4N/A
PX161301_HighBloodPressure_Date_Of_Onset_MonthPX161301012201High Blood Pressure Date of Onset - Month4N/A
PX161301_HighBloodPressure_Date_Of_Onset_DayPX161301012202High Blood Pressure Date of Onset - Day4N/A
PX161301_HighBloodPressure_Date_Of_Onset_YearPX161301012203High Blood Pressure Date of Onset - Year4N/A
PX161301_HypoglycemiaPX161301012300Hypoglycemia4N/A
PX161301_Hypoglycemia_Date_Of_Onset_MonthPX161301012301Hypoglycemia Date of Onset- Month4N/A
PX161301_Hypoglycemia_Date_Of_Onset_DayPX161301012302Hypoglycemia Date of Onset- Day4N/A
PX161301_Hypoglycemia_Date_Of_Onset_YearPX161301012303Hypoglycemia Date of Onset- Year4N/A
PX161301_JaundicePX161301012400Jaundice4N/A
PX161301_Jaundice_Date_Of_Onset_MonthPX161301012401Jaundice Date of Onset - Month4N/A
PX161301_Jaundice_Date_Of_Onset_DayPX161301012402Jaundice Date of Onset - Day4N/A
PX161301_Jaundice_Date_Of_Onset_YearPX161301012403Jaundice Date of Onset - Year4N/A
PX161301_Kidney_DiseasePX161301012500Kidney Disease4N/A
PX161301_KidneyDisease_Date_Of_Onset_MonthPX161301012501Kidney Disease Date of Onset - Month4N/A
PX161301_KidneyDisease_Date_Of_Onset_DayPX161301012502Kidney Disease Date of Onset - Day4N/A
PX161301_KidneyDisease_Date_Of_Onset_YearPX161301012503Kidney Disease Date of Onset - Year4N/A
PX161301_Low_Blood_PressurePX161301012600Low Blood Pressure4N/A
PX161301_LowBloodPressure_Date_Of_Onset_MonthPX161301012601Low Blood Pressure Date of Onset - Month4N/A
PX161301_LowBloodPressure_Date_Of_Onset_DayPX161301012602Low Blood Pressure Date of Onset - Day4N/A
PX161301_LowBloodPressure_Date_Of_Onset_YearPX161301012603Low Blood Pressure Date of Onset - Year4N/A
PX161301_Mental_RetardationPX161301012700Mental Retardation4N/A
PX161301_MentalRetardation_Date_Of_Onset_MonthPX161301012701Mental Retardation Date of Onset - Month4N/A
PX161301_MentalRetardation_Date_Of_Onset_DayPX161301012702Mental Retardation Date of Onset - Day4N/A
PX161301_MentalRetardation_Date_Of_Onset_YearPX161301012703Mental Retardation Date of Onset - Year4N/A
PX161301_ChestPainPX161301012800Pain or Pressure in Chest4N/A
PX161301_ChestPain_Date_Of_Onset_MonthPX161301012801Pain or Pressure in Chest Date of Onset - Month4N/A
PX161301_ChestPain_Date_Of_Onset_DayPX161301012802Pain or Pressure in Chest Date of Onset - Day4N/A
PX161301_ChestPain_Date_Of_Onset_YearPX161301012803Pain or Pressure in Chest Date of Onset - Year4N/A