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Long NameMedical History NCI Standard Template
DefinitionThe collection of CDEs used in the Medical History module.
Protocol Long NameNCI Standard Template Forms
Public ID2733828
Module Long NameModule InstructionsQuestionCDECDE Public IDCDE VersionQuestion InstructionsValue Domain Data TypeValue Domain Unit of MeasureDisplay FormatValid ValueForm Value Meaning TextForm Value Meaning Desc.
Mandatory Medical History QuestionsThis must be included when this data is collected for reporting.
Medical History DatePatient Relevant Medical History Date21796592.0Enter the date that the medical history is collected.DATEMM/DD/YYYY
Optional Medical History QuestionsThere is no requirement for inclusion of these elements on the case report form. If the design and scientific questions posed in the study dictate the need to collect this type of data, these elements should be included.
OngoingPersonal Medical History Ongoing Indicator27368811.0Enter whether the medical history condition is ongoing at the time of collection.CHARACTER
NoNoThe non-affirmative response to a question.
YesYesThe affirmative response to a question or activity.
N/ANot ApplicableDetermination of a value is not relevant in the current context.
DescriptionMedical History Description20038743.0Enter description of medical history at the time of collection.CHARACTER
FindingMedical History Review of Systems Finding Type31925501.0Enter the result of the assessment for a particular body system.CHARACTER
Not AssessedNo AssessmentThe non-affirmative response to a question.: Having determined the value, significance, or extent of.
AbnormalAbnormalDeviating from the norm.
NormalNormalBeing approximately average or within certain limits; conforming with or constituting a norm or standard or level or type or social norm. (NCI)
Body SystemMedical History Review of Systems Criteria Category31925401.0Enter the body system.CHARACTER
AbdomenAbdomenOf, or related to, the abdomen.
BreastsBreastOne of two hemispheric projections of variable size situated in the subcutaneous layer over the pectoralis major muscle on either side of the chest.
CardiovascularCardiovascular SystemRelating to the heart and the blood vessels or the circulation.
DermatologicDermatologicHaving to do with the skin, relating to or practicing dermatology.
Endocrine/MetabolicEndocrine SystemThe system of glands that release their secretions (hormones) directly into the circulatory system. In addition to the ENDOCRINE GLANDS, included are the CHROMAFFIN SYSTEM and the NEUROSECRETORY SYSTEMS.
GastrointestinalGastrointestinal SystemThe system that includes the esophagus, stomach, small and large intestine, anus, liver, biliary tract, and pancreas.
GenitourinaryGenitourinary SystemThe body system that includes all organs involved in reproduction and in the formation and voidance of urine.
HEENTHead, Ears, Eyes, Nose and ThroatHEENT is the Head, Ears, Eyes, Nose and Throat, and is referred to as a body system on a physical or medical examination. The term is typically used as 'HEENT' in a physician or caregiver notes.
Hematopoietic/Lymph Nodes(s)Hematopoietic and Lymphatic SystemThe bodily system of organs and tissues, primarily the bone marrow, spleen, tonsils, and lymph nodes, involved in the production of blood considered together with the interconnected system of spaces and vessels between body tissues and organs by which lymph circulates throughout the body.
ImmuneImmune Systemincludes the thymus, spleen, lymphatic system, bone marrow, tonsils, and Peyer's patches, and the migratory cells these organs generate: lymphocytes, granulocytes, and cells of the monocyte- macrophage type.
MusculoskeletalMusculoskeletal SystemThe system of muscles, tendons, ligaments, bones, joints and associated tissues that move the body and maintain its form.
NeckNeckThe region that connects the head to the rest of the body.
NeurologicNeurologic ExaminationThe assessment of the functionality of the brain, spinal column, and nerves.
OtherOtherDifferent than the one(s) previously specified or mentioned.
PelvisPelvic ExaminationA complete physical examination of a woman's external and internal reproductive organs by a health professional.
PsychologicPsychologicalHaving to do with how the mind works and how thoughts and feelings affect behavior.
RespiratoryRespiratory System(RES-pih-ra-tor-ee) The organs that are involved in breathing. These include the nose, throat, larynx, trachea, bronchi, and lungs.Also known as the respiratory tract.
Other (Body) System/Site TextOther Body System/Site Text21826711.0Enter description of other body system/site.CHARACTER
Medical History Assessment IndicatorPatient Personal Medical History Assessment Indicator31988061.0Enter whether the medical history was assessed/gathered.CHARACTER
YesYesThe affirmative response to a question or activity.
NoNoThe non-affirmative response to a question.