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Protocol - Medical History

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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

 
Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

Personnel and Training Required

None

Equipment Needs

None

Requirements
Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Self- or proxy-administered questionnaire

Life Stage:

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

Participants:

Any age group

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.

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 Date 2543596 CDE Browser
Logical Observation Identifiers Names and Codes (LOINC) Medical history proto 62890-9 LOINC
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_AIDS PX161301010200 Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive 4 Variable Mapping
PX161301_AIDS_Date_Of_Onset_Day PX161301010202 Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive Date of Onset - Day 4 N/A
PX161301_AIDS_Date_Of_Onset_Month PX161301010201 Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive Date of Onset - Month 4 N/A
PX161301_AIDS_Date_Of_Onset_Year PX161301010203 Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive Date of Onset -Year 4 Variable Mapping
PX161301_Arthritis PX161301010300 Arthritis 4 Variable Mapping
PX161301_Arthritis_Date_Of_Onset_Day PX161301010302 Arthritis Date of Onset - Day 4 N/A
PX161301_Arthritis_Date_Of_Onset_Month PX161301010301 Arthritis Date of Onset - Month 4 N/A
PX161301_Arthritis_Date_Of_Onset_Year PX161301010303 Arthritis Date of Onset - Year 4 Variable Mapping
PX161301_Asthma PX161301010400 Asthma 4 Variable Mapping
PX161301_Asthma_Date_Of_Onset_Day PX161301010402 Asthma Date of Onset - Day 4 N/A
PX161301_Asthma_Date_Of_Onset_Month PX161301010401 Asthma Date of Onset - Month 4 N/A
PX161301_Asthma_Date_Of_Onset_Year PX161301010403 Asthma Date of Onset - Year 4 Variable Mapping
PX161301_Bronchitis PX161301010500 Bronchitis 4 Variable Mapping
PX161301_Bronchitis_Date_Of_Onset_Day PX161301010502 Bronchitis Date of Onset - Day 4 N/A
PX161301_Bronchitis_Date_Of_Onset_Month PX161301010501 Bronchitis Date of Onset - Month 4 N/A
PX161301_Bronchitis_Date_Of_Onset_Year PX161301010503 Bronchitis Date of Onset - Year 4 Variable Mapping
PX161301_Cancer PX161301010600 Cancer 4 Variable Mapping
PX161301_Cancer_Date_Of_Onset_Day PX161301010602 Cancer Date of Onset - Day 4 N/A
PX161301_Cancer_Date_Of_Onset_Month PX161301010601 Cancer Date of Onset - Month 4 Variable Mapping
PX161301_Cancer_Date_Of_Onset_Year PX161301010603 Cancer Date of Onset - Year 4 Variable Mapping
PX161301_ChestPain PX161301012800 Pain or Pressure in Chest 4 N/A
PX161301_ChestPain_Date_Of_Onset_Day PX161301012802 Pain or Pressure in Chest Date of Onset - Day 4 N/A
PX161301_ChestPain_Date_Of_Onset_Month PX161301012801 Pain or Pressure in Chest Date of Onset - Month 4 N/A
PX161301_ChestPain_Date_Of_Onset_Year PX161301012803 Pain or Pressure in Chest Date of Onset - Year 4 N/A
PX161301_Chlamydia PX161301010700 Chlamydia 4 Variable Mapping
PX161301_Chlamydia_Date_Of_Onset_Day PX161301010702 Chlamydia Date of Onset - Day 4 N/A
PX161301_Chlamydia_Date_Of_Onset_Month PX161301010701 Chlamydia Date of Onset - Month 4 N/A
PX161301_Chlamydia_Date_Of_Onset_Year PX161301010703 Chlamydia Date of Onset - Year 4 N/A
PX161301_Diabetes PX161301010800 Diabetes 4 N/A
PX161301_Diabetes_Date_Of_Onset_Day PX161301010802 Diabetes Date of Onset - Day 4 N/A
PX161301_Diabetes_Date_Of_Onset_Month PX161301010801 Diabetes Date of Onset - Month 4 N/A
PX161301_Diabetes_Date_Of_Onset_Year PX161301010803 Diabetes Date of Onset - Year 4 N/A
PX161301_Dizziness PX161301010900 Dizziness 4 N/A
PX161301_Dizziness_Date_Of_Onset_Day PX161301010902 Dizziness Date of Onset - Day 4 N/A
PX161301_Dizziness_Date_Of_Onset_Month PX161301010901 Dizziness Date of Onset - Month 4 N/A
PX161301_Dizziness_Date_Of_Onset_Year PX161301010903 Dizziness Date of Onset - Year 4 N/A
PX161301_Emphysema PX161301011000 Emphysema 4 N/A
PX161301_Emphysema_Date_Of_Onset_Day PX161301011002 Emphysema Date of Onset - Day 4 N/A
PX161301_Emphysema_Date_Of_Onset_Month PX161301011001 Emphysema Date of Onset - Month 4 N/A
PX161301_Emphysema_Date_Of_Onset_Year PX161301011003 Emphysema Date of Onset - Year 4 N/A
PX161301_Epilepsy PX161301011100 Epilepsy 4 N/A
PX161301_Epilepsy_Date_Of_Onset_Day PX161301011102 Epilepsy Date of Onset - Day 4 N/A
PX161301_Epilepsy_Date_Of_Onset_Month PX161301011101 Epilepsy Date of Onset - Month 4 N/A
PX161301_Epilepsy_Date_Of_Onset_Year PX161301011103 Epilepsy Date of Onset - Year 4 N/A
PX161301_Eye_Problem PX161301011200 Eye Problem 4 N/A
PX161301_Eye_Problem_Date_Of_Onset_Day PX161301011202 Eye Problem Date of Onset - Day 4 N/A
PX161301_Eye_Problem_Date_Of_Onset_Month PX161301011201 Eye Problem Date of Onset - Month 4 N/A
PX161301_Eye_Problem_Date_Of_Onset_Year PX161301011203 Eye Problem Date of Onset - Year 4 N/A
PX161301_Fainting PX161301011300 Fainting 4 N/A
PX161301_Fainting_Date_Of_Onset_Day PX161301011302 Fainting Date of Onset - Day 4 N/A
PX161301_Fainting_Date_Of_Onset_Month PX161301011301 Fainting Date of Onset - Month 4 N/A
PX161301_Fainting_Date_Of_Onset_Year PX161301011303 Fainting Date of Onset - Year 4 N/A
PX161301_Glaucoma PX161301011500 Glaucoma 4 N/A
PX161301_Glaucoma_Date_Of_Onset_Day PX161301011502 Glaucoma Date of Onset - Day 4 N/A
PX161301_Glaucoma_Date_Of_Onset_Month PX161301011501 Glaucoma Date of Onset - Month 4 N/A
PX161301_Glaucoma_Date_Of_Onset_Year PX161301011503 Glaucoma Date of Onset -Year 4 N/A
PX161301_Gonorrhea PX161301011600 Gonorrhea 4 N/A
PX161301_Gonorrhea_Date_Of_Onset_Day PX161301011602 Gonorrhea Date of Onset - Day 4 N/A
PX161301_Gonorrhea_Date_Of_Onset_Month PX161301011601 Gonorrhea Date of Onset - Month 4 N/A
PX161301_Gonorrhea_Date_Of_Onset_Year PX161301011603 Gonorrhea Date of Onset - Year 4 N/A
PX161301_Headaches PX161301011400 Frequent or Severe Headaches 4 N/A
PX161301_Headaches_Date_Of_Onset_Day PX161301011402 Frequent or Severe Headaches Date of Onset - Day 4 N/A
PX161301_Headaches_Date_Of_Onset_Month PX161301011401 Frequent or Severe Headaches Date of Onset - Month 4 N/A
PX161301_Headaches_Date_Of_Onset_Year PX161301011403 Frequent or Severe Headaches Date of Onset - Year 4 N/A
PX161301_HearingImpairment_Date_Of_Onset_Day PX161301011702 Hearing Impairment Date of Onset - Day 4 N/A
PX161301_HearingImpairment_Date_Of_Onset_Month PX161301011701 Hearing Impairment Date of Onset - Month 4 N/A
PX161301_HearingImpairment_Date_Of_Onset_Year PX161301011703 Hearing Impairment Date of Onset - Year 4 N/A
PX161301_Hearing_Impairment PX161301011700 Hearing Impairment 4 N/A
PX161301_HeartCondition_Date_Of_Onset_Day PX161301011802 Heart Condition Date of Onset - Day 4 N/A
PX161301_HeartCondition_Date_Of_Onset_Month PX161301011801 Heart Condition Date of Onset - Month 4 N/A
PX161301_HeartCondition_Date_Of_Onset_Year PX161301011803 Heart Condition Date of Onset - Year 4 N/A
PX161301_Heart_Condition PX161301011800 Heart Condition 4 N/A
PX161301_Hemodialysis PX161301011900 Hemodialysis 4 N/A
PX161301_Hemodialysis_Date_Of_Onset_Day PX161301011902 Hemodialysis Date of Onset - Day 4 N/A
PX161301_Hemodialysis_Date_Of_Onset_Month PX161301011901 Hemodialysis Date of Onset - Month 4 N/A
PX161301_Hemodialysis_Date_Of_Onset_Year PX161301011903 Hemodialysis Date of Onset - Year 4 N/A
PX161301_Herpes PX161301012000 Herpes 4 N/A
PX161301_Herpes_Date_Of_Onset_Day PX161301012002 Herpes Date of Onset - Day 4 N/A
PX161301_Herpes_Date_Of_Onset_Month PX161301012001 Herpes Date of Onset - Month 4 N/A
PX161301_Herpes_Date_Of_Onset_Year PX161301012003 Herpes Date of Onset - Year 4 N/A
PX161301_HighBloodCholesterol_Date_Of_Onset_Day PX161301012102 High Blood Cholesterol Date of Onset - Day 4 N/A
PX161301_HighBloodCholesterol_Date_Of_Onset_Month PX161301012101 High Blood Cholesterol Date of Onset - Month 4 N/A
PX161301_HighBloodCholesterol_Date_Of_Onset_Year PX161301012103 High Blood Cholesterol Date of Onset - Year 4 N/A
PX161301_HighBloodPressure_Date_Of_Onset_Day PX161301012202 High Blood Pressure Date of Onset - Day 4 N/A
PX161301_HighBloodPressure_Date_Of_Onset_Month PX161301012201 High Blood Pressure Date of Onset - Month 4 N/A
PX161301_HighBloodPressure_Date_Of_Onset_Year PX161301012203 High Blood Pressure Date of Onset - Year 4 N/A
PX161301_High_Blood_Cholesterol PX161301012100 High Blood Cholesterol 4 N/A
PX161301_High_Blood_Pressure PX161301012200 High Blood Pressure 4 N/A
PX161301_Hypoglycemia PX161301012300 Hypoglycemia 4 N/A
PX161301_Hypoglycemia_Date_Of_Onset_Day PX161301012302 Hypoglycemia Date of Onset- Day 4 N/A
PX161301_Hypoglycemia_Date_Of_Onset_Month PX161301012301 Hypoglycemia Date of Onset- Month 4 N/A
PX161301_Hypoglycemia_Date_Of_Onset_Year PX161301012303 Hypoglycemia Date of Onset- Year 4 N/A
PX161301_Jaundice PX161301012400 Jaundice 4 N/A
PX161301_Jaundice_Date_Of_Onset_Day PX161301012402 Jaundice Date of Onset - Day 4 N/A
PX161301_Jaundice_Date_Of_Onset_Month PX161301012401 Jaundice Date of Onset - Month 4 N/A
PX161301_Jaundice_Date_Of_Onset_Year PX161301012403 Jaundice Date of Onset - Year 4 N/A
PX161301_KidneyDisease_Date_Of_Onset_Day PX161301012502 Kidney Disease Date of Onset - Day 4 N/A
PX161301_KidneyDisease_Date_Of_Onset_Month PX161301012501 Kidney Disease Date of Onset - Month 4 N/A
PX161301_KidneyDisease_Date_Of_Onset_Year PX161301012503 Kidney Disease Date of Onset - Year 4 N/A
PX161301_Kidney_Disease PX161301012500 Kidney Disease 4 N/A
PX161301_LowBloodPressure_Date_Of_Onset_Day PX161301012602 Low Blood Pressure Date of Onset - Day 4 N/A
PX161301_LowBloodPressure_Date_Of_Onset_Month PX161301012601 Low Blood Pressure Date of Onset - Month 4 N/A
PX161301_LowBloodPressure_Date_Of_Onset_Year PX161301012603 Low Blood Pressure Date of Onset - Year 4 N/A
PX161301_Low_Blood_Pressure PX161301012600 Low Blood Pressure 4 N/A
PX161301_MentalRetardation_Date_Of_Onset_Day PX161301012702 Mental Retardation Date of Onset - Day 4 N/A
PX161301_MentalRetardation_Date_Of_Onset_Month PX161301012701 Mental Retardation Date of Onset - Month 4 N/A
PX161301_MentalRetardation_Date_Of_Onset_Year PX161301012703 Mental Retardation Date of Onset - Year 4 N/A
PX161301_Mental_Retardation PX161301012700 Mental Retardation 4 N/A
PX161301_Other PX161301014100 Other 4 N/A
PX161301_Other_Date_Of_Onset_Day PX161301014103 Other Date of Onset - Day 4 N/A
PX161301_Other_Date_Of_Onset_Month PX161301014102 Other Date of Onset - Month 4 N/A
PX161301_Other_Specify PX161301014101 Other, specify 4 N/A
PX161301_Palpitations PX161301012900 Palpitations 4 N/A
PX161301_Palpitations_Date_Of_OnsetYear PX161301012903 Palpitations Date of Onset-Year 4 N/A
PX161301_Palpitations_Date_Of_Onset_Day PX161301012902 Palpitations Date of Onset- Day 4 N/A
PX161301_Palpitations_Date_Of_Onset_Month PX161301012901 Palpitations Date of Onset- Month 4 N/A
PX161301_Periods_Of_Unconsciousness PX161301013000 Periods of Unconsciousness 4 N/A
PX161301_RheumaticFever_Date_Of_Onset_Day PX161301013102 Rheumatic Fever Date of Onset - Day 4 N/A
PX161301_RheumaticFever_Date_Of_Onset_Month PX161301013101 Rheumatic Fever Date of Onset - Month 4 N/A
PX161301_RheumaticFever_Date_Of_Onset_Year PX161301013103 Rheumatic Fever Date of Onset - Year 4 N/A
PX161301_Rheumatic_Fever PX161301013100 Rheumatic Fever 4 N/A
PX161301_Rheumatism PX161301013200 Rheumatism 4 N/A
PX161301_Rheumatism_Date_Of_Onset_Day PX161301013202 Rheumatism Date of Onset - Day 4 N/A
PX161301_Rheumatism_Date_Of_Onset_Month PX161301013201 Rheumatism Date of Onset - Month 4 N/A
PX161301_Rheumatism_Date_Of_Onset_Year PX161301013203 Rheumatism Date of Onset - Year 4 N/A
PX161301_Seizures PX161301013300 Seizures 4 N/A
PX161301_Seizures_Date_Of_Onset_Day PX161301013302 Seizures Date of Onset - Day 4 N/A
PX161301_Seizures_Date_Of_Onset_Month PX161301013301 Seizures Date of Onset - Month 4 N/A
PX161301_Seizures_Date_Of_Onset_Year PX161301013303 Seizures Date of Onset - Year 4 N/A
PX161301_ShortnessOfBreath_Date_Of_Onset_Day PX161301013402 Shortness of Breath Date of Onset - Day 4 N/A
PX161301_ShortnessOfBreath_Date_Of_Onset_Month PX161301013401 Shortness of Breath Date of Onset - Month 4 N/A
PX161301_ShortnessOfBreath_Date_Of_Onset_Year PX161301013403 Shortness of Breath Date of Onset - Year 4 N/A
PX161301_Shortness_Of_Breath PX161301013400 Shortness of Breath 4 N/A
PX161301_StomachLiverIntestinal_Date_Of_Onset_Day PX161301013502 Stomach Liver or Intestinal Problems Date of Onset - Day 4 N/A
PX161301_StomachLiverIntestinal_Date_Of_Onset_Month PX161301013501 Stomach Liver or Intestinal Problems Date of Onset - Month 4 N/A
PX161301_StomachLiverIntestinal_Date_Of_Onset_Year PX161301013503 Stomach Liver or Intestinal Problems Date of Onset - Year 4 N/A
PX161301_Stomach_Liver_Problems PX161301013500 Stomach or Liver Problems 4 N/A
PX161301_Syphilis PX161301013600 Syphilis 4 N/A
PX161301_Syphilis_Date_Of_Onset_Day PX161301013602 Syphilis Date of Onset - Day 4 N/A
PX161301_Syphilis_Date_Of_Onset_Month PX161301013601 Syphilis Date of Onset - Month 4 N/A
PX161301_Syphilis_Date_Of_Onset_Year PX161301013603 Syphilis Date of Onset - Year 4 N/A
PX161301_Thyroid_Date_Of_Onset_Day PX161301013902 Thyroid Problems Date of Onset - Day 4 N/A
PX161301_Thyroid_Date_Of_Onset_Month PX161301013901 Thyroid Problems Date of Onset - Month 4 N/A
PX161301_Thyroid_Date_Of_Onset_Year PX161301013903 Thyroid Problems Date of Onset - Year 4 N/A
PX161301_Thyroid_Problems PX161301013900 Thyroid Problems 4 N/A
PX161301_Tuberculosis PX161301013700 Tuberculosis 4 N/A
PX161301_Tuberculosis_Date_Of_OnsetDay PX161301013702 Tuberculosis Date of Onset-Day 4 N/A
PX161301_Tuberculosis_Date_Of_OnsetMonth PX161301013701 Tuberculosis Date of Onset-Month 4 N/A
PX161301_Tuberculosis_Date_Of_OnsetYear PX161301013703 Tuberculosis Date of Onset-Year 4 N/A
PX161301_Tumor PX161301013800 Tumor 4 N/A
PX161301_Tumor_Date_Of_Onset_Day PX161301013802 Tumor Date of Onset - Day 4 N/A
PX161301_Tumor_Date_Of_Onset_Month PX161301013801 Tumor Date of Onset - Month 4 N/A
PX161301_Tumor_Date_Of_Onset_Year PX161301013803 Tumor Date of Onset - Year 4 N/A
PX161301_Unconsciousness_Date_Of_Onset_Day PX161301013002 Periods of Unconsciousness Date of Onset - Day 4 N/A
PX161301_Unconsciousness_Date_Of_Onset_Month PX161301013001 Periods of Unconsciousness Date of Onset - Month 4 N/A
PX161301_Unconsciousness_Date_Of_Onset_Year PX161301013003 Periods of Unconsciousness Date of Onset - Year 4 N/A
PX161301_UrinaryTractInfection_Date_Of_Onset_Day PX161301014002 Urinary Tract Infection Date of Onset - Day 4 N/A
PX161301_UrinaryTractInfection_Date_Of_Onset_Month PX161301014001 Urinary Tract Infection Date of Onset - Month 4 N/A
PX161301_UrinaryTractInfection_Date_Of_Onset_Year PX161301014003 Urinary Tract Infection Date of Onset - Year 4 N/A
PX161301_Urinary_Tract_Problems PX161301014000 Urinary Tract Problems 4 N/A
Research Domain Information
Measure Name:

Medical History

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.

Keywords

Infectious Diseases, Medical History, American Health Information Management Association, AHIMA, My Personal Health Record, MyPHR, Infectious Diseases and Immunity