CDE Detailed Report

Disease: Headache
Subdomain Name: History of Disease/Injury Event
CRF: Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire

Displaying 1 - 50 of 52
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
C59661 Headache prior diagnosis type HdchPriorDxTyp Type of prior headache history diagnosis Type of prior headache history diagnosis If 'Yes', please check all that apply Migraine with aura;Migraine without aura;Chronic Migraine;Other;Episodic cluster headache;Chronic cluster headache;Cervicogenic headache;Infrequent episodic tension-type headache;Frequent episodic tension-type headache;Chronic tension-type headache Migraine with aura;Migraine without aura;Chronic Migraine;Other;Episodic cluster headache;Chronic cluster headache;Cervicogenic headache;Infrequent episodic tension-type headache;Frequent episodic tension-type headache;Chronic tension-type headache Alphanumeric

Choose all that apply; Only answer if 'YES' is answered to "Does patient have a prior headache diagnosis?"

Adult;Pediatric Supplemental 1.00 2023-08-14 22:00:18.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59672 Headache severe before traumatic brain injury average monthly frequency HdchSevereBfrTBIAvgMoFreq Average monthly frequency of headaches the participant/subject experienced with severe severity prior to traumatic brain injury Average monthly frequency of headaches the participant/subject experienced with severe severity prior to traumatic brain injury Prior to the TBI, what was the average monthly headache frequency of any kind with severe severity 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 Numeric Values

Indicate average number of days

Adult;Pediatric Supplemental 1.00 2023-08-14 22:21:35.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C16208 Family history medical condition second-degree relative type FamHistMedclCondScndDegReltTyp Relationship of the second-degree family member or ancestor with the medical condition or health related event to the participant/subject Relationship of the second-degree family member or ancestor with the medical condition or health related event to the participant/subject Relationship of second-degree relative(s) to participant/subject 11;12;13;14;15;16;17;18;19;20;21;22;23;24 Half-Sibling Male;Half-Sibling Female;Maternal Grandmother;Maternal Grandfather;Paternal Grandmother;Paternal Grandfather;Maternal Aunt;Maternal Uncle;Paternal Aunt;Paternal Uncle;Grandchild Male;Grandchild Female;Nephew;Niece Numeric Values Adult;Pediatric Supplemental 3.00 2013-07-16 14:01:43.01 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59683 Memory concentration difficult without headache indicator MemCncntrnDffcltWthoutHdchInd Indicator of whether participant/subject experienced difficulty with memory/concentration without a headache Indicator of whether participant/subject experienced difficulty with memory/concentration without a headache Difficulty with memory/concentration Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:39:26.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59640 Headache additional symptom unilateral same side present indicator HdchAddtnlSympUnilatSmSdPrsInd Indicator of whether the participant's/subject's symptom is present on the same side to the headache Indicator of whether the participant's/subject's symptom is present on the same side to the headache If 'Unilateral', is Symptom Present on Same Side to Headache? Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:18:48.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59662 Headache prior diagnosis type other text HdchPriorDxTypOTH The free-text field related to 'Headache prior diagnosis type' specifying other text The free-text field related to 'Headache prior diagnosis type' specifying other text Other Alphanumeric

Only answer if 'YES' is answered to "Does patient have a prior headache diagnosis?"

Adult;Pediatric Supplemental 1.00 2023-08-14 22:02:58.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events 255

Free-Form Entry

C59673 Headache before traumatic brain injury complete freedom monthly day count HdchBfrTBICmplFreeMnthDyCt Count of monthly frequency of complete freedom from headache the participant/subject experienced prior to traumatic brain injury Count of monthly frequency of complete freedom from headache the participant/subject experienced prior to traumatic brain injury Prior to the TBI, how many days per month (30 days) did the individual have complete headache freedom 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 Numeric Values

Indicate number of days

Adult;Pediatric Supplemental 1.00 2023-08-14 22:22:26.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C19035 Headache aura symptom other text HdchAurasSymOTH The free-text field related to 'Headache aura symptom type' specifying other text. Type of aura (warning) that a headache was going to start The free-text field related to 'Headache aura symptom type' specifying other text. Type of aura (warning) that a headache was going to start Other, specify Alphanumeric Adult;Pediatric Supplemental 3.10 2023-08-14 20:18:00.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events 4000

Free-Form Entry

C59684 Aura without headache indicator AuraWthoutHdchInd Indicator of whether participant/subject experienced an aura without a headache Indicator of whether participant/subject experienced an aura without a headache Aura without headache Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:41:46.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59641 Headache aura occurrence indicator HdchAuraOccurInd Indicator of whether the participant/subject has an aura occur with headache Indicator of whether the participant/subject has an aura occur with headache Auras with headaches Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:22:36.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59663 Headache first date HdchFirstDate Date of the participant's/subject's first headache Date of the participant's/subject's first headache Date of first headache Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

ISO 8601 - https://www.iso.org/iso-8601-date-and-time-format.html Adult;Pediatric Supplemental 1.00 2023-08-14 22:06:19.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

C59674 Headache before traumatic brain injury continuous indicator HdchBfrTBICntInd Indicator of whether headaches experienced by the participant/subject were continuous prior to traumatic brain injury Indicator of whether headaches experienced by the participant/subject were continuous prior to traumatic brain injury Were headaches prior to the TBI continuous (i.e., no periods of headache freedom) Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:23:51.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59630 Headache laterality anatomic site HdchLateralAnatSite Anatomic site location of the headache Anatomic site location of the headache Where were the headaches usually located? Right;Left;Front;Back;Top;Side/Temples Right;Left;Front;Back;Top;Side/Temples Alphanumeric

Choose all that apply

Adult;Pediatric Supplemental 1.00 2023-08-14 21:04:11.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59642 Headache aura symptom type frequency category HdchAuraSympTypFreqCat Category that describes how the aura symptom type effects the participant/subject Category that describes how the aura symptom type effects the participant/subject Did the individual experience the following aura types with headaches Never;Almost Never;Sometimes;Often;Almost always Never;Almost Never;Sometimes;Often;Almost always Alphanumeric

Choose one

Adult;Pediatric Supplemental 1.00 2023-08-14 21:24:09.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59664 Headache after traumatic brain injury change indicator HdchAftrTBIChngInd Indicator of whether the participant's/subject's headaches after a traumatic brain injury changed followingf the TBI Indicator of whether the participant's/subject's headaches after a traumatic brain injury changed followingf the TBI Did the headache that was present prior to TBI change following TBI? Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:07:34.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59675 Headache before traumatic brain injury noncontinuous inadequate treatment duration HdchBfrTBINnctnInadqTxDur Duration of participant/subject's inadequately treated noncontinuous headache Duration of participant/subject's inadequately treated noncontinuous headache If headaches were not continuous, how long did headaches last if untreated/inadequately treated? Numeric Values

Duration is recorded in hours and minutes (HH:MM)

Adult;Pediatric Supplemental 1.00 2023-08-14 22:24:45.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

C59631 Headache laterality type HdchLateralTyp Type of side were headache is located Type of side were headache is located What side(s) was the headache(s) usually on Right only;Left only;Both sides;Alternating sides Right only;Left only;Both sides;Alternating sides Alphanumeric

Choose all that apply

Adult;Pediatric Supplemental 1.00 2023-08-14 21:06:04.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59643 Headache aura experience percent value HdchAuraExprncPctVal Value of (the percentage of) headaches the participant/subject experience with auras Value of (the percentage of) headaches the participant/subject experience with auras Percentage of headaches experienced with auras Numeric Values Adult;Pediatric Supplemental 1.00 2023-08-14 21:25:45.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

0 100 percent
C15897 Headache associated symptom type HdchAssocSymptmTyp The associated symptoms the participant/subject experienced with headache Type of symptoms associated with the headache Symptom Nausea;Vomiting;Sensitive to light;Sensitive to noise;Neck Pain/Stiffness;Dizziness and/or vertigo;Gait and/or postural imbalance;Difficulty with memory/concentration Nausea;Vomiting;Sensitive to light;Sensitive to noise;Neck Pain/Stiffness;Dizziness and/or vertigo;Gait and/or postural imbalance;Difficulty with memory/concentration Alphanumeric

Choose all that apply

Adult;Pediatric Supplemental 3.00 2013-07-16 14:01:43.01 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59665 Headache after traumatic brain injury intensity change indicator HdchAfterTBIIntnseChngInd Indicator of whether the participant/subject is experiencing more intense headaches following traumatic brain injury Indicator of whether the participant/subject is experiencing more intense headaches following traumatic brain injury Are headaches more intense following TBI? Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:10:06.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59676 Nausea without headache indicator NausWthoutHdchInd Indicator of whether participant/subject experienced nausea without a headache Indicator of whether participant/subject experienced nausea without a headache Nausea Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:31:29.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59632 Headache maximum pain intensity scale HdchMaxPainIntstyScl Rating scale of the maximum headache pain intensity described by the participant/subject Rating scale of the maximum headache pain intensity described by the participant/subject Maximum headache pain intensity: 0 (no pain) to 10 (most severe pain) scale 0;1;2;3;4;5;6;7;8;9;10 0;1;2;3;4;5;6;7;8;9;10 Numeric Values

"0" = no pain and "10" = most severe pain

Adult;Pediatric Supplemental 1.00 2023-08-14 21:07:20.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59655 Headache category HeadacheCat Type of headache experienced by the participant/subject Type of headache experienced by the participant/subject Headache Type Migraine;Post Traumatic Headache;Other Headache Migraine;Post Traumatic Headache;Other Headache Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:50:50.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C15917 Headache typical pain intensity rate scale HeadacheTypPainIntstyRateScl Rating scale for the pain of this headache on a scale of 0 -10 Rating scale for the pain of this headache on a scale of 0 -10 Typical headache pain intensity: 0 (no pain) to 10 (most severe pain) scale 0;1;2;3;4;5;6;7;8;9;10 0;1;2;3;4;5;6;7;8;9;10 Numeric Values

"0" = no pain and "10" = most severe pain

Adult;Pediatric Supplemental 4.10 2023-06-02 10:23:14.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59666 Headache after traumatic brain injury frequency change indicator HdchAfterTBIFreqChngInd Indicator of whether the participant/subject is experiencing more frequenct headaches following traumatic brain injury Indicator of whether the participant/subject is experiencing more frequenct headaches following traumatic brain injury Are headaches more frequent following TBI? Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:11:06.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59677 Vomit without headache indicator VomitWthoutHdchInd Indicator of whether participant/subject experienced vomiting without a headache Indicator of whether participant/subject experienced vomiting without a headache Vomiting Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:32:32.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59634 Headache worse with neck movement indicator HdchWorseWthNeckMvmtInd Indicator of whether the subject's/participant's headaches worsen with neck movements Indicator of whether the subject's/participant's headaches worsen with neck movements Headaches worse with neck movements Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:10:43.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59656 Headache category other text HeadacheCatOTH The free-text field related to 'Headache category' specifying other text The free-text field related to 'Headache category' specifying other text Other Headache Type Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:52:09.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events 255

Free-Form Entry

C15937 Headache typical severity type HeadachTypclSevertyTyp Level of headache intensity described by the participant/subject Level of headache intensity described by the participant/subject Intensity Mild;Moderate;Severe Mild;Moderate;Severe Alphanumeric

Choose one

Adult;Pediatric Supplemental 3.10 2023-08-14 08:41:42.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59667 Headache after traumatic brain injury symptom change indicator HdchAfterTBISympChngInd Indicator of whether the participant's/subject's headaches symptoms changed following traumatic brain injury Indicator of whether the participant's/subject's headaches symptoms changed following traumatic brain injury Are headaches associated with new characteristics (e.g., changes in quality, location, or 'associated symptoms' i.e., nausea, vomiting, dizziness, vertigo, or photophobia) following TBI? Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:13:08.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59678 Light sensitive without headache indicator LightSensitvWthoutHdchInd Indicator of whether participant/subject experienced sensitivity to light without a headache Indicator of whether participant/subject experienced sensitivity to light without a headache Sensitivity to light Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:33:42.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59635 Headache worse with mental activity indicator HdchWorseWthMentalActvInd Indicator of whether the subject's/participant's headaches worsen with mental activity Indicator of whether the subject's/participant's headaches worsen with mental activity Headaches worse with mental activity (e.g., reading, concentration) Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:11:41.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59657 Headache type family history indicator HeadacheTypFamHxInd Indicator as to whether the participant/subject has a family history of diagnosed headache type Indicator as to whether the participant/subject has a family history of diagnosed headache type Family History of Headache Type? Yes;No;Unknown Yes;No;Unknown Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:53:18.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C15950 Headache typical pain type HdchTypcPainTyp Type of pain the participant/subject experiences with the headache Type of pain the participant/subject experiences with the headache Quality Stabbing;Burning;Pressure/Aching;Pulsating/Throbbing Stabbing;Burning;Pressure/Aching;Pulsating/Throbbing Alphanumeric

Choose all that apply

Adult;Pediatric Supplemental 3.00 2013-07-16 14:01:43.01 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59668 Headache symptom change after traumatic brain injury type HdchSympChngAftrTBITyp Type of headache symptoms experienced by the participant/subject following traumatic brain injury Type of headache symptoms experienced by the participant/subject following traumatic brain injury If 'Yes', please select associated symptoms Nausea;Vomiting;Photophobia;Phonophobia;Vertigo;Dizziness (not vertigo);Throbbing pain;Pain with touching the scalp;Worsening of headache with routine physical activity like walking or climbing stairs Nausea;Vomiting;Photophobia;Phonophobia;Vertigo;Dizziness (not vertigo);Throbbing pain;Pain with touching the scalp;Worsening of headache with routine physical activity like walking or climbing stairs Alphanumeric

Choose all that apply. Only answer if 'YES' is answered to 'Did headaches change in other characteristics e.g., changes in quality, location, or 'associated symptoms' i.e., nausea, vomiting, dizziness, vertigo, or photophobia following TBI

Adult;Pediatric Supplemental 1.00 2023-08-14 22:14:16.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59679 Sound sensitive without headache indicator SoundSensitvWthoutHdchInd Indicator of whether participant/subject experienced sensitivity to sound without a headache Indicator of whether participant/subject experienced sensitivity to sound without a headache Sensitivity to sound Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:34:58.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59636 Headache associated symptom type frequency category HdchAssocSymptmTypFreqCat Category that describes how frequently the headache associated symptom type effects the participant/subject Category that describes how frequently the headache associated symptom type effects the participant/subject Did the individual experience the following symptoms during headache Never;Almost Never;Sometimes;Often;Almost always Never;Almost Never;Sometimes;Often;Almost always Alphanumeric

Choose one

Adult;Pediatric Supplemental 1.00 2023-08-14 21:12:27.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59658 Relative biological first degree diagnosis headache history indicator RelatvBioFrstDegrDxHxHdchInd Indicator of whether first-degree biological relatives of the participant/subject has a history of diagnosed headache Indicator of whether first-degree biological relatives of the participant/subject has a history of diagnosed headache First Degree Biological Relative? Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:54:17.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C15961 Headache worse during activity indicator HeadachWorsDurngActvtyInd Indicates whether activity or playing makes headache worse Indicates whether activity or playing makes headache worse Headaches worse with physical activity Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-16 14:01:43.01 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59669 Headache before traumatic brain injury monthly frequency HdchBfrTBIMnthFreq Frequency of monthly headaches the participant/subject experienced prior to traumatic brain injury Frequency of monthly headaches the participant/subject experienced prior to traumatic brain injury Prior to the TBI, how many days per month (30 days) did the individual have a headache of any duration (minutes or hours) of any severity (mild, moderate or severe)? 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 Numeric Values

Indicate number of days

Adult;Pediatric Supplemental 1.00 2023-08-14 22:15:11.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59680 Neck pain stiffness without headache indicator NeckPainStffnssWthoutHdchInd Indicator of whether participant/subject experienced neck pain/stiffness without a headache Indicator of whether participant/subject experienced neck pain/stiffness without a headache Neck Pain/Stiffness Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:35:53.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59637 Headache additional symptom type HdchAddtnlSymptmTyp Type of additional symptoms the participant/subject experienced with headache Type of additional symptoms the participant/subject experienced with headache Headache Symptom Miosis (i.e., excessive constriction of the pupil of the eye);Aural fullness (i.e., stuffy ears or fluid in the ears);Conjunctival Injection (i.e., white of eye gets red);Tearing;Nasal congestion;Eyelid swelling;Eyelid drooping;Facial sweating Miosis (i.e., excessive constriction of the pupil of the eye);Aural fullness (i.e., stuffy ears or fluid in the ears);Conjunctival Injection (i.e., white of eye gets red);Tearing;Nasal congestion;Eyelid swelling;Eyelid drooping;Facial sweating Alphanumeric

Choose all that apply

Adult;Pediatric Supplemental 1.00 2023-08-14 21:13:24.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59659 Headache before traumatic brain injury history indicator HdchBfrTBIHxInd Indicator of whether the participant/subject had experienced headaches prior to traumatic brain injury Indicator of whether the participant/subject had experienced headaches prior to traumatic brain injury Headaches prior to TBI No;Yes No;Yes Alphanumeric

If 'NO', then questionnaire is complete

Adult;Pediatric Supplemental 1.00 2023-08-14 21:58:17.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59670 Headache mild before traumatic brain injury average monthly frequency HdchMildBfrTBIAvgMnthFreq Average monthly frequency of headaches the participant/subject experienced with mild severity prior to traumatic brain injury Average monthly frequency of headaches the participant/subject experienced with mild severity prior to traumatic brain injury Prior to the TBI, what was the average monthly headache frequency of any kind with mild severity 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 Numeric Values

Indicate average number of days

Adult;Pediatric Supplemental 1.00 2023-08-14 22:17:56.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C15972 Headache aura symptom type HdchAurasSymTyp Type of aura (warning) that a headache was going to start Type of aura (warning) that a headache was going to start Aura Visual;Sensory;Speech and/or Language;Motor;Brainstem;Retinal;Other, specify Visual;Sensory;Speech and/or Language;Motor;Brainstem;Retinal;Other, specify Alphanumeric

Choose all that apply

Adult;Pediatric Supplemental 3.10 2023-08-14 20:18:35.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C59681 Dizziness vertigo without headache indicator DizzinessVertigoWthoutHdchInd Indicator of whether participant/subject experienced dizziness and/or vertigo without a headache Indicator of whether participant/subject experienced dizziness and/or vertigo without a headache Dizziness and/or vertigo Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 22:36:54.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59638 Headache additional symptom type present indicator HdchAddtnlSympTypPresentInd Indicator of whether the participant's/subject's headache symptom is present Indicator of whether the participant's/subject's headache symptom is present Is Symptom Present? Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2023-08-14 21:15:53.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59660 Headache prior diagnosis indicator HdchPriorDxInd Indicator of whether the participant/subject had a prior headache diagnosis Indicator of whether the participant/subject had a prior headache diagnosis Does patient have a prior headache diagnosis? Yes;No Yes;No Alphanumeric

If 'YES' then answer the following questions regarding characteristics of pre-TBI headaches

Adult;Pediatric Supplemental 1.00 2023-08-14 21:59:21.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C59671 Headache moderate before traumatic brain injury average monthly frequency HdchModrtBfrTBIAvgMoFreq Average monthly frequency of headaches the participant/subject experienced with moderate severity prior to traumatic brain injury Average monthly frequency of headaches the participant/subject experienced with moderate severity prior to traumatic brain injury Prior to the TBI, what was the average monthly headache frequency of any kind with moderate severity 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 0;1;2;3;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18;19;20;21;22;23;24;25;26;27;28;29;30 Numeric Values

Indicate average number of days

Adult;Pediatric Supplemental 1.00 2023-08-14 22:20:31.0 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C16207 Family history medical condition first-degree relative type FamHistMedclCondFrstDegReltTyp Relationship of the first-degree family member or ancestor with the medical condition or health related event to the participant/subject Relationship of the first-degree family member or ancestor with the medical condition or health related event to the participant/subject Relationship of first-degree relative(s) to
participant/subject
1;2;3;4;5;6;7;8;9;10 Biological Mother;Biological Father;Sibling Male;Sibling Female;Non-identical or dizygotic twin Male;Non-identical or dizygotic twin Female;Identical twin Male;Identical twin Female;Full biologic child Male;Full biologic child Female Numeric Values Adult;Pediatric Supplemental 3.00 2013-07-16 14:01:43.01 Post-traumatic Headache (PTH) - Headaches Prior to TBI Questionnaire History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

CSV