CDE Detailed Report
Disease: Mitochondrial Disease
Subdomain Name: General Health History
CRF: Dietary Supplements
Displaying 1 - 13 of 13
Subdomain Name: General Health History
CRF: Dietary Supplements
Displaying 1 - 13 of 13
| CDE ID | CDE Name | Variable Name | Definition | Short Description | Question Text | Permissible Values | Description | Data Type | Disease Specific Instructions | Disease Specific Reference | Population | Classification (e.g., Core) | Version Number | Version Date | CRF Name (CRF Module / Guidance) | Subdomain Name | Domain Name | Size | Input Restrictions | Min Value | Max Value | Measurement Type | External Id Loinc | External Id Snomed | External Id caDSR | External Id CDISC |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| C59695 | Dietary supplement study use day count | DietrSupplStdyUseDayCt | Count of days the participant took dietary supplements before or during the study | Count of days the participant took dietary supplements before or during the study | Yes (# of days) | Numeric Values |
No instructions available |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2024-02-01 08:26:40.0 | Dietary Supplements | General Health History | Participant History and Family History |
Free-Form Entry |
day | |||||||||
| C59696 | Dietary supplement multivitamin or mineral name | DietrSupplMultivitmnOrMnrlName | Name of the multivitamin or multivitamin/mineral dietary supplement taken | Name of the multivitamin or multivitamin/mineral dietary supplement taken | Multivitamin or Multivitamin/Mineral Supplements (list) | Alphanumeric |
No instructions available |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2024-02-01 08:34:08.0 | Dietary Supplements | General Health History | Participant History and Family History | 255 |
Free-Form Entry |
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| C59697 | Dietary supplement individual name | DietrSupplIndividualName | Name of the individual dietary supplement taken | Name of the individual dietary supplement taken | Individual dietary supplements not listed above | Alphanumeric |
No instructions available |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2024-02-01 08:47:06.0 | Dietary Supplements | General Health History | Participant History and Family History | 255 |
Free-Form Entry |
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| C59698 | Dietary supplement dose unit of measure | DietrSupplDoseUOM | Unit of measure for the dose of the dietary supplement the participant is taking | Unit of measure for the dose of the dietary supplement the participant is taking | Dose | Alphanumeric |
Record the strength and units of the dietary supplement the participant is taking |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2024-02-01 08:48:02.0 | Dietary Supplements | General Health History | Participant History and Family History | 255 |
Free-Form Entry |
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| C59699 | Dietary supplement route type other text | DietrSupplRouteTypOTH | The free-text field related to 'Dietary supplement route type', specifying other type. Type of administration route for the dietary supplement | The free text field related to 'Dietary supplement route type', specifying other type. Type of administration route for the dietary supplement | Other, specify | Alphanumeric |
Record the route of administration |
No references available | Adult;Pediatric | Supplemental | 1.00 | 2024-02-01 08:50:15.0 | Dietary Supplements | General Health History | Participant History and Family History | 4000 |
Free-Form Entry |
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| C19714 | Dietary supplement study use indicator | DietrSupplStdyUseInd | Indicator of whether the participant took dietary supplements before or during the study | Indicator of whether the participant took dietary supplements before or during the study | Did the participant take any dietary supplements before or during the study? | No;Yes | No;Yes | Alphanumeric |
Choose one. If this question is answered YES then at least one prior/concomitant dietary supplement record needs to be recorded. Do NOT record study dietary supplements taken (if study has a dietary supplement intervention) on this form |
No references available | Adult;Pediatric | Supplemental | 1.10 | 2024-02-01 08:56:22.0 | Dietary Supplements | General Health History | Participant History and Family History |
Single Pre-Defined Value Selected |
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| C19715 | Dietary supplement generic name | DietrSupplGenrName | Generic name for the supplement taken | Generic name for the supplement taken | Dietary Supplement Generic Name | Biotin;Folic Acid;Folinic acid;Vitamin B1 (thiamin);Vitamin B2 (riboflavin);Vitamin B3 (niacin);Vitamin B6 (pyridoxine);Vitamin C (ascorbic acid);Vitamin D2 (ergocalciferol);Vitamin D3 (cholecalciferol);Calcium;Magnesium;Selenium;Arginine;Citrate;Citrulline;N-acetyl cysteine;Succinate;Uridine;Other;Alpha-lipoic acid (thioctic acid);Beta Carotene;Bicarbonate;Brewer's yeast;Choline;Chromium;Cod liver oil;Coenzyme Q10 as ubiquinol;Coenzyme Q10 as ubiquinone;DHEA;Dichloroacetate;Echinacea;Evening primrose;Fiber;Flax Seed Oil;Flaxseed;Ginkgo;Ginseng;Glucosamine/Chondroitin;Idebenone;L-Carnitine;Lecithin;Lycopene;Melatonin;Methylfolate;Nicotinamide riboside;Omega-3 fatty acids;Polyphenols;Pyrroloquinoline quinone (PQQ);Saw Palmetto;Soy Protein Powder;Soy Supplements;Turmeric;Vitamin B12 (cobalamin);Vitamin E (tocopherol);Vitamin K (phylloquinone);Weight Loss Supplements;Wheat Germ;Zinc;St. John's Wort;Creatine;Phosphorus | Biotin;Folic Acid;Folinic acid;Vitamin B1 (thiamin);Vitamin B2 (riboflavin);Vitamin B3 (niacin);Vitamin B6 (pyridoxine);Vitamin C (ascorbic acid);Vitamin D2 (ergocalciferol);Vitamin D3 (cholecalciferol);Calcium;Magnesium;Selenium;Arginine;Citrate;Citrulline;N-acetyl cysteine;Succinate;Uridine;Other;Alpha-lipoic acid (thioctic acid);Beta Carotene;Bicarbonate;Brewer's yeast;Choline;Chromium;Cod liver oil;Coenzyme Q10 as ubiquinol;Coenzyme Q10 as ubiquinone;DHEA;Dichloroacetate;Echinacea;Evening primrose;Fiber;Flax Seed Oil;Flaxseed;Ginkgo;Ginseng;Glucosamine/Chondroitin;Idebenone;L-Carnitine;Lecithin;Lycopene;Melatonin;Methylfolate;Nicotinamide riboside;Omega-3 fatty acids;Polyphenols;Pyrroloquinoline quinone (PQQ);Saw Palmetto;Soy Protein Powder;Soy Supplements;Turmeric;Vitamin B12 (cobalamin);Vitamin E (tocopherol);Vitamin K (phylloquinone);Weight Loss Supplements;Wheat Germ;Zinc;St. John's Wort;Creatine;Phosphorus | Alphanumeric |
Record the verbatim name (generic or trade name) of the dietary supplement(s) the participant reports taking. Dietary supplements may be taken as a commercial multivitamin or multivitamin/mineral preparation (e.g., a children's chewable multivitamin), individual nutrients (e.g., individual vitamins or minerals), or specially compounded formulations (e.g., a mitochondrial specific formulation which may be referred to as a "mitochondrial cocktail") |
NIH Office of Dietary Supplements. Dietary Supplements for Primary Mitochondrial Disorders. Bethesda, MD: National Institutes of Health Available from: https://ods.od.nih.gov/factsheets/PrimaryMitochondrialDisorders-HealthProfessional/#coQ | Adult;Pediatric | Supplemental | 2.00 | 2024-02-01 09:06:08.0 | Dietary Supplements | General Health History | Participant History and Family History |
Multiple Pre-Defined Values Selected |
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| C19716 | Dietary supplement compounded formulation ingredient text | DietrSupplCompFormlIngTxt | Free-text field to specify list of ingredients used to make a specially compounded formulation | Free-text field to specify list of ingredients used to make a specially compounded formulation | Specially Compounded Formulations (list ingredients) | Alphanumeric |
No instructions available |
No references available | Adult;Pediatric | Supplemental | 1.10 | 2024-02-01 09:15:15.0 | Dietary Supplements | General Health History | Participant History and Family History | 255 |
Free-Form Entry |
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| C19717 | Dietary supplement brand formulation name | DietrSupplBrandFormName | Name of the dietary supplement brand or formulation taken | Name of the dietary supplement brand or formulation taken | Brand/formulation | Alphanumeric |
Record the brand name and chemical form. For example, for calcium, indicate if it is calcium carbonate, calcium citrate, etc. |
No references available | Adult;Pediatric | Supplemental | 1.10 | 2024-02-01 09:19:21.0 | Dietary Supplements | General Health History | Participant History and Family History | 255 |
Free-Form Entry |
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| C19718 | Dietary supplement indication reason | DietrSupplIndicatnRsn | Reason the participant is taking the dietary supplement | Reason the participant is taking the dietary supplement | Indication | Alphanumeric |
Record the reason the participant gives for taking the dietary supplement |
No references available | Adult;Pediatric | Supplemental | 1.10 | 2024-02-01 09:22:21.0 | Dietary Supplements | General Health History | Participant History and Family History | 255 |
Free-Form Entry |
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| C19719 | Dietary supplement dose | DietrSupplDose | Dose of the dietary supplement the participant is taking | Dose of the dietary supplement the participant is taking | Dose | Numeric Values |
Record the strength and units of the dietary supplement the participant is taking |
No references available | Adult;Pediatric | Supplemental | 2.00 | 2024-02-01 09:24:54.0 | Dietary Supplements | General Health History | Participant History and Family History |
Free-Form Entry |
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| C19720 | Dietary supplement dose frequency text | DietrSupplDoseFreqTxt | The free-text field describing the frequency of use of the dietary supplement | The free-text field describing the frequency of use of the dietary supplement | Frequency | Alphanumeric |
Record how often the dietary supplement is being taken |
Adult;Pediatric | Supplemental | 2.00 | 2024-03-05 11:25:03.0 | Dietary Supplements | General Health History | Participant History and Family History | 255 |
Free-Form Entry |
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| C19721 | Dietary supplement route type | DietrSupplRouteTyp | Type of administration route for the dietary supplement | Type of administration route for the dietary supplement | Route | Buccal;Inhaled;Intramuscular;Intravenous / Parenteral;Nasal;By mouth;Enteral (via tube);Subcutaneous;Sublingual;Transdermal;Unknown;Other, specify | Buccal;Inhaled;Intramuscular;Intravenous / Parenteral;Nasal;By mouth;Enteral (via tube);Subcutaneous;Sublingual;Transdermal;Unknown;Other, specify | Alphanumeric |
Record the route of administration |
No references available | Adult;Pediatric | Supplemental | 2.00 | 2024-02-01 09:43:44.0 | Dietary Supplements | General Health History | Participant History and Family History |
Multiple Pre-Defined Values Selected |
