Field Properties

Study # 18 (LOIS)

Plate # 1 (Eligibility, p1)

7 Number ID001[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials001[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: Plate Exit:

9 Choice subjpart[subjpart] Will Subject Partiicpate?Style: YN CheckNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecEligDate(); ecOtherSpecify(2);

10 String reasnotpart[reasnotpart] Reason Not ParticipatingStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 24 Store: 96Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: 1

Field Enter: Field Exit: Plate Exit:

11 Date confrmdt[confrmdt] Consent Form Sig DateStyle: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 Date isurgdt[isurgdt] Index Surgery DateStyle: VisitDateNeed: Required Hidden: No Reason level: 0Legal: 01/AUG/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Inherit

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Choice inc1[inc1] Inc Crit #1Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: notEligInclusion()

14 Choice inc2[inc2] Inc Crit #2Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter:

2

Field Enter: Field Exit: Plate Exit:

15 Choice inc3[inc3] Inc Crit #3Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 Choice exc1[exc1] Excl Crit #1Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: notEligExclusion1()

17 Choice exc2[exc2] Excl Crit #2Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Choice exc3[exc3] Excl Crit #3Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

3

19 Choice exc4[exc4] Excl Crit #4Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

20 Choice exc5[exc5] Excl Crit #5Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

21 Choice exc6[exc6] Excl Crit #6Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

22 Choice exc7[exc7] Excl Crit #7Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

23 Choice exc8[exc8] Excl Crit #8Style: YN CheckNeed: Optional Hidden: No Reason level: 0Legal:

4

Help: No Box: 0 Not checked

Box 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

24 Date eligdt[eligdt] Eligibility DateStyle: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

25 Check invagreeelig[invagreeelig] Investigator Agrees EligibleStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: ecInvOnly()Field Enter:

Field Exit: Plate Exit:

26 String LCUser001[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

27 String LCDate001[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

5

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

28 String LCTime001[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 8 Store: 8Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: ecHideUser()Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 41 (Follow-up visit, p1)

6 Choice visitseq041[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID041[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials041[initials] InitialsStyle: InitialsNeed: Required Hidden: No Reason level: 0Legal:

6

Help: Initials of patientDisplay: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Date fuvisdt[fuvisdt] Follow-Up Visit DateStyle: VisitDateNeed: Required Hidden: No Reason level: 0Legal: 01/AUG/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Inherit

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice fuwalkstatus[fuwalkstatus] FU Ambulatory StatusStyle: Walk StatusNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Ambulatory without assistanceBox 2: 2 Ambulatory with assistive deviceBox 3: 3 Cannot walk

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(3)

11 String reascannotwalk[reascannotwalk] Reason Cannot WalkStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 43 Store: 88Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 String ambcomm[ambcomm] Amb Status CommentsStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

7

Display: 45 Store: 999Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Choice fuworkstat[fuworkstat] FU Work StatusStyle: Work statusNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Working full t imeBox 2: 2 Working part timeBox 3: 3 Not working, studentBox 4: 4 Not working, retiredBox 5: 5 Not working due to back painBox 6: 6 Not working other reason

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Choice fupainprevwk[fupainprevwk] FU Pain Prevents WorkingStyle: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(1)

15 Number fuhrslimit[fuhrslimit] FU Hours Limit WorkingStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: 0.5-80Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 String workstatcom[workstatcom] Not Working Other ReasonStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 18 Store: 255

8

Format: Mapping: None

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 String painprevworkcom[painprevworkcom] Pain Prevents Work CommentStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 25 Store: 255Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Choice aelast041[aelast041] AE Since Last ContactStyle: NY CheckNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 2 NoBox 2: 1 Yes

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

19 String LCUser041[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

20 String LCDate041[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter:

9

Field Enter: Field Exit: Plate Exit:

21 String LCTime041[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 8 Store: 8Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: ecHideUser()Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 42 (Follow-up visit, p2)

6 Choice visitseq042[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID042[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials042[initials] InitialsStyle: InitialsNeed: Required Hidden: No Reason level: 0Legal: Help: Initials of patient

Display: 3 Store: 3Format:

10

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Check funarcnt[funarcnt] FU Not Taking NarcoticsStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 9 fields if value equals 1Plate Enter: ecNoMed(9)Field Enter:

Field Exit: ecNoMed(9)Plate Exit:

10 Number narcday1[narcday1] Days Taking Narcotic 1Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Number narcdose1[narcdose1] Narcotic Dose 1 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 String narcname1[narcname1] Narcotic Name 1Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

11

13 Number narcday2[narcday2] Days Taking Narcotic 2Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Number narcdose2[narcdose2] Narcotic Dose 2 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 String narcname2[narcname2] Narcotic Name 2Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 Number narcday3[narcday3] Days Taking Narcotic 3Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 Number narcdose3[narcdose3] Narcotic Dose 3 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

12

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 String narcname3[narcname3] Narcotic Name 3Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

19 Check funsaidnt[funsaidnt] FU Not Taking NSAIDsStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

20 Number nsaidday1[nsaidday1] Days Taking NSAID 1Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

21 Number nsaiddose1[nsaiddose1] NSAID Dose 1 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

22 String nsaidname1[nsaidname1] NSAID Name 1

13

Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

23 Number nsaidday2[nsaidday2] Days NSAID Narcotic 2Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

24 Number nsaiddose2[nsaiddose2] NSAID Dose 2 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

25 String nsaidname2[nsaidname2] NSAID Name 2Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

26 Number nsaidday3[nsaidday3] Days Taking NSAID 3Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

14

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

27 Number nsaiddose3[nsaiddose3] NSAID Dose 3 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

28 String nsaidname3[nsaidname3] NSAID Name 3Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

29 Check fumuscnt[fumuscnt] FU Not Taking Musc RelaxStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

30 Number muscday1[muscday1] Days Taking Musc Relax 1Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

31 Number muscdose1[muscdose1] Musc Relax Dose 1 (mg)

15

Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

32 String muscname1[muscname1] Musc Relax Name 1Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

33 Number muscday2[muscday2] Days Taking Musc Relax 2Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

34 Number muscdose2[muscdose2] Musc Relax Dose 2 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

35 String muscname2[muscname2] Musc Relax Name 2Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: None

16

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

36 Number muscday3[muscday3] Days Taking Musc Relax 3Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

37 Number muscdose3[muscdose3] Musc Relax Dose 3 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

38 String muscname3[muscname3] Musc Relax Name 3Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

39 Check fudepnt[fudepnt] FU Not Taking AntiDepressantsStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

40 Number antidepday1[antidepday1] Days Taking Antidepress 1

17

Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

41 Number antidepdose1[antidepdose1] Antidepress Dose 1 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

42 String antidepname1[antidepname1] Antidepress Name 1Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

43 Number antidepday2[antidepday2] Days Taking Antidepress 2Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

44 Number antidepdose2[antidepdose2] Antidepress Dose 2 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals

18

Plate Enter: Field Enter:

Field Exit: Plate Exit:

45 String antidepname2[antidepname2] Antidepress Name 2Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 23 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

46 Check fumedpainnotSIJ[fumedpainnotSIJ] FU Pain Meds Not for SIJStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

47 Number nonSIJday1[nonSIJday1] Days Taking NonSIJ Med 1Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

48 Number nonSIJdose1[nonSIJdose1] NonSIJ Med Dose 1 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

49 String nonSIJname1[nonSIJname1] NonSIJ Med Name 1Style: SimpleString

19

Need: Optional Hidden: No Reason level: 0Legal: Help:

Display: 17 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

50 String nonSIJconname1[nonSIJconname1] Non-SIJ Condition 1Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 17 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

51 Number nonSIJday2[nonSIJday2] Days Taking NonSIJ Med 2Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

52 Number nonSIJdose2[nonSIJdose2] NonSIJ Med Dose 2 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

53 String nonSIJname2[nonSIJname2] NonSIJ Med Name 2Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 17 Store: 66Format:

Mapping: None

20

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

54 String nonSIJconname2[nonSIJconname2] Non-SIJ Condition 2Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 17 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

55 Number nonSIJday3[nonSIJday3] Days Taking NonSIJ Med 3Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

56 Number nonSIJdose3[nonSIJdose3] NonSIJ Med Dose 3 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

57 String nonSIJname3[nonSIJname3] NonSIJ Med Name 3Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 17 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

21

58 String nonSIJconname3[nonSIJconname3] Non-SIJ Condition 3Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 17 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

59 Number nonSIJday4[nonSIJday4] Days Taking NonSIJ Med 4Style: Days 2wksNeed: Optional Hidden: No Reason level: 0Legal: 0-14Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

60 Number nonSIJdose4[nonSIJdose4] NonSIJ Med Dose 4 (mg)Style: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 4 Store: 4Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

61 String nonSIJname4[nonSIJname4] NonSIJ Med Name 4Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 17 Store: 66Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

62 String nonSIJconname4[nonSIJconname4] Non-SIJ Condition 4Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 17 Store: 66

22

Format: Mapping: None

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

63 String LCUser042[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

64 String LCDate042[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

65 String LCTime042[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 8 Store: 8Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: ecHideUser()Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 44 (Follow-up visit, p3)

6 Choice visitseq044[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checked

23

Choice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID044[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials044[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Choice fuvasdone[fuvasdone] FU VAS DoneStyle: YN CheckNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice fuodidone[fuodidone] FU ODI DoneStyle: YN CheckNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Yes

24

Box 2: 2 NoSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Choice fueq5ddone[fueq5ddone] FU EQ5D DoneStyle: YN CheckNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 Choice fusatdone[fusatdone] FU Satisfaction DoneStyle: YN CheckNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Choice fudsijqdone[fudsijqdone] FU DSIJQ DoneStyle: YN CheckNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Choice fuzungdone[fuzungdone] FU Zung DoneStyle: YN CheckNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

25

Field Exit: Plate Exit:

15 Choice revdone[revdone] Revision DoneStyle: SimpleChoiceNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 RightBox 2: 2 LeftBox 3: 3 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecRevision()

16 Choice reopdone[reopdone] Reoperation DoneStyle: SimpleChoiceNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 RightBox 2: 2 LeftBox 3: 3 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecRevision()

17 String revdesc[revdesc] Revision DescriptionStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 49 Store: 555Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Date revdt[revdt] Revision DateStyle: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

26

Field Exit: Plate Exit:

19 String revcom[revcom] Revision CommentsStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 45 Store: 777Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

Plate # 45 (Follow-up visit, p4)

6 Choice visitseq045[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID045[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials045[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To Upper

27

Skip: 0 fields if value equals Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Choice hrct5[hrct5] HR CT Done at 5 YearsStyle: SimpleChoiceNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 Not requiredBox 3: 3 Not done

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Date hrctsentdt[hrctsentdt] HR CT Date SentStyle: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 String reasctnd[reasctnd] Reason HRCT Not DoneStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 33 Store: 231Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 String LCUser045[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

28

Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 String LCDate045[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 String LCTime045[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 13 Store: 13Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 46 (Healthcare Util Not Req Study)

6 Choice visitseq046[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID046[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

29

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials046[initials] InitialsStyle: InitialsNeed: Required Hidden: No Reason level: 0Legal: Help: Initials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Check nophysvis[nophysvis] No Add Physician VisitsStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 1 fields if value equals 1Plate Enter: ecMask(1)Field Enter:

Field Exit: ecMask(1)Plate Exit:

10 Number addphysvis[addphysvis] Additional Physician VisitsStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Check noaddproc[noaddproc] No Additional ProceduresStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 9 fields if value equals 1Plate Enter: ecMask(9)Field Enter:

Field Exit: ecMask(9)Plate Exit:

30

12 Number addinj[addinj] Additional SIJ InjectionsStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Number addrfa[addrfa] Additional RFA ProceduresStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 String addproc1[addproc1] Additional Procedures (1)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 30 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 String addproc2[addproc2] Additional Procedures (2)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 30 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 String addproc3[addproc3] Additional Procedures (3)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

31

Display: 30 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 String addproc4[addproc4] Additional Procedures (4)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 30 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Number addchir[addchir] Additional Visits to ChiropractorStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

19 Number addacu[addacu] Additional Visits to AcupuncturistStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

20 Number addpro[addpro] Additional Visits for ProlotherapyStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit:

32

Plate Exit:

21 Check noaddrad[noaddrad] No Additional RadiographsStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 3 fields if value equals 1Plate Enter: ecMask(3)Field Enter:

Field Exit: ecMask(3)Plate Exit:

22 Number addMRI[addMRI] Additional MRIsStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

23 Number addCT[addCT] Additional CTsStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

24 Number addXray[addXray] Additional X-RaysStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

25 Check noaddptot[noaddptot] No Additional PT/OTStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 Unchecked

33

Check On: 1 CheckedSkip: 2 fields if value equals 1

Plate Enter: ecMask(2)Field Enter:

Field Exit: ecMask(2)Plate Exit:

26 Number addPT[addPT] Additional Visits to Phys TherapyStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

27 Number addOT[addOT] Additional Visits to Occup TherapStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

28 Check noaddmedeq[noaddmedeq] No Additional Medical EquipmentStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 4 fields if value equals 1Plate Enter: ecMask(4)Field Enter:

Field Exit: ecMask(4)Plate Exit:

29 String medequip1[medequip1] Medical Equipment (1)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 30 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

34

30 String medequip2[medequip2] Medical Equipment (2)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 30 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

31 String medequip3[medequip3] Medical Equipment (3)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 30 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

32 String medequip4[medequip4] Medical Equipment (4)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 30 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

Plate # 51 (Phone call)

6 Choice visitseq051[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter:

35

Field Enter: Field Exit: Plate Exit:

7 Number ID051[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials051[initials] InitialsStyle: InitialsNeed: Required Hidden: No Reason level: 0Legal: Help: Initials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Date phonedt[phonedt] Phone DateStyle: VisitDateNeed: Required Hidden: No Reason level: 0Legal: 01/AUG/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Inherit

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice phwalkstatus[phwalkstatus] Phone Ambulatory StatusStyle: Walk StatusNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Ambulatory without assistanceBox 2: 2 Ambulatory with assistive deviceBox 3: 3 Cannot walk

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit:

36

Plate Exit: ecOtherSpecify(3)

11 String nowalkrs[nowalkrs] Reason Cannot WalkStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 32 Store: 32Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 String phambcom[phambcom] Ambulatory Comments (Phone)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 61 Store: 610Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Choice phworkstat[phworkstat] Phone Work StatusStyle: Work statusNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Working full t imeBox 2: 2 Working part timeBox 3: 3 Not working, studentBox 4: 4 Not working, retiredBox 5: 5 Not working due to back painBox 6: 6 Not working other reason

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Choice phpainprevwk[phpainprevwk] Phone Pain Prevents WorkingStyle: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit:

37

Plate Exit: ecOtherSpecify(1)

15 Number phhrslimit[phhrslimit] Phone Hours Limit WorkingStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: 0.5-80Help:

Display: 2 Store: 2Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 String workstatcomph[workstatcomph] Not Working Other Reason (Phone)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 18 Store: 255Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 String painprevworkcomph[painprevworkcomph] Pain Prevents Work Comment (Phone)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 38 Store: 114Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Choice aelast051[aelast051] AE Since Last ContactStyle: NY CheckNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 2 NoBox 2: 1 Yes

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

19 Choice revdoneph[revdoneph] Revision Done (Phone)Style: SimpleChoiceNeed: Required Hidden: No Reason level: 0

38

Legal: Help:

No Box: 0 Not checkedBox 1: 1 RightBox 2: 2 LeftBox 3: 3 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecRevision()

20 Choice reopdoneph[reopdoneph] Reoperation Done (Phone)Style: SimpleChoiceNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 RightBox 2: 2 LeftBox 3: 3 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecRevision()

21 String revdesc[revdesc] Revision DescriptionStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 49 Store: 555Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

22 Date revdtph[revdtph] Revision Date (Phone)Style: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

23 String revcomph[revcomph] Revision Comments (Phone)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0

39

Legal: Help:

Display: 45 Store: 777Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

Plate # 101 (Study Exit)

7 Number ID101[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials101[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Date exitdt[exitdt] Exit DateStyle: VisitDateNeed: Required Hidden: No Reason level: 0Legal: 01/AUG/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Inherit

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice exited[exited] Study ExitStyle: SimpleChoice

40

Need: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 CompletedBox 2: 2 Discont Premature

Skip: 3 fields if value equals 1Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(2)

11 Choice reasexit[reasexit] Reason ExitStyle: SimpleChoiceNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Withdrew consentBox 2: 2 AE prevent participationBox 3: 3 DeathBox 4: 4 LTFUBox 5: 5 Other

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(5)

12 String reasexitother[reasexitother] Reason Exit Other (Explain)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 37 Store: 111Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 String exitcomm[exitcomm] Exit CommentsStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 37 Store: 111Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Check invrev[invrev] Investigator Review of CRFStyle: SimpleCheckNeed: Required Hidden: No Reason level: 0

41

Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: ecInvOnly()Field Enter:

Field Exit: Plate Exit:

15 String LCUser101[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 String LCDate101[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 String LCTime101[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 13 Store: 13Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 111 (Unscheduled Visit)

6 Number unsvisitID111[unsvisitID] Unscheduled Visit IDStyle: Unsched VisitIDNeed: Essential Hidden: No Reason level: 0Legal: 601-620

42

Help: Display: 3 Store: 3Format: 6nn

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID111[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials111[initials] InitialsStyle: InitialsNeed: Required Hidden: No Reason level: 0Legal: Help: Initials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Date unsvisdt[unsvisdt] Unscheduled Visit DateStyle: WIC DateNeed: Essential Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice unvisae[unvisae] Unscheduled Visit Due to AEStyle: YN CheckNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

43

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Number aenumIDref[aenumIDref] AE Number ID ReferenceStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: 301-320Help:

Display: 3 Store: 3Format: 3nn

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 String unsviscom[unsviscom] Unscheduled Visit CommentStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 48 Store: 48Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Check imgxr[imgxr] Image: X-RayStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Check imgmri[imgmri] Image: X-RayStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 Check imgct[imgct] Image: X-Ray

44

Style: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 Check imgoth[imgoth] Image: X-RayStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(1)

17 String imgothsp[imgothsp] Imaging Other SpecifyStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Choice imagingdn[imagingdn] Imaging Done This Visit?Style: YN CheckNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

19 String imgcom[imgcom] Imaging CommentsStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 45 Store: 444Format:

45

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

20 String unscom2[unscom2] Unscheduled Comments 2Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 70 Store: 490Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

Plate # 113 (Deviation)

6 Number devID[devID] Deviation IDStyle: Deviation IDNeed: Essential Hidden: No Reason level: 0Legal: 201-240Help:

Display: 3 Store: 3Format: 2nn

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID113[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials113[initials] InitialsStyle: InitialsNeed: Required Hidden: No Reason level: 0Legal: Help: Initials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

46

Plate Enter: Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials

9 Choice devtime[devtime] Deviation TimingStyle: SimpleChoiceNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 EligBox 2: 2 2.5 yBox 3: 3 3 yBox 4: 4 3.5 yBox 5: 5 4 yBox 6: 6 4.5 yBox 7: 7 5 yBox 8: 8 ExitBox 9: 9 AE

Box 10: 10 UnschBox 11: 11 Other

Skip: 1 fields if value equals 1-15Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(10)

10 Number AEIDRef[AEIDRef] AE ID referenceStyle: SimpleNumberNeed: Optional Hidden: No Reason level: 0Legal: 301-399Help:

Display: 3 Store: 3Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Date pdunsvisdt[pdunsvisdt] Unsch Visit Date DeviationStyle: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 String devtimothr[devtimothr] Deviation Timing Other (Spec)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0

47

Legal: Help:

Display: 12 Store: 35Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Choice devtype[devtype] Deviation TypeStyle: SimpleChoiceNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Cons form not signedBox 2: 2 Not meet elig criteriaBox 3: 3 Test/proc not doneBox 4: 4 Test/proc not acc protocolBox 5: 5 Test/proc outside windowBox 6: 6 Visit not doneBox 7: 7 Visit outside windowBox 8: 8 Other

Skip: 3 fields if value equals 1-8Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(8)

14 String devtypeother[devtypeother] Deviation Type Other (Spec)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 27 Store: 27Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 String devdesc[devdesc] Deviation DescriptionStyle: SimpleStringNeed: Required Hidden: No Reason level: 0Legal: Help:

Display: 56 Store: 156Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 Choice rptdev[rptdev] Deviation Reported to IRB?

48

Style: SimpleChoiceNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 Not requiredBox 3: 3 No

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 Date irbrptdt[irbrptdt] IRB Report DateStyle: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 String irbnotrprs[irbnotrprs] Not Reported to IRB ReasonStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 34 Store: 666Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

19 Check invrevdev[invrevdev] Investigator Reviewed DeviationStyle: SimpleCheckNeed: Required Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: ecInvOnly()Field Enter:

Field Exit: Plate Exit:

20 String LCUser113[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0

49

Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

21 String LCDate113[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

22 String LCTime113[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 8 Store: 8Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: ecHideUser()Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 121 (Adverse Event, p1)

6 Number AEID121[AEID] Adverse Event IDStyle: AE IDNeed: Essential Hidden: No Reason level: 0Legal: 301-340Help:

Display: 3 Store: 3Format: 3nn

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID121[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)

50

Help: Site ID*1000 + ptIDDisplay: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials121[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Date aestartdt[aestartdt] AE Start DateStyle: WIC DateNeed: Required Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 String aedesc[aedesc] AE Description (Short)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 50 Store: 155Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 String aedesclong[aedesclong] AE Descr LongStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 49 Store: 900Format:

51

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 Choice ifuseexp[ifuseexp] iFuse Explanted As Result of AEStyle: NY CheckNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 2 NoBox 2: 1 Yes

Skip: 1 fields if value equals 2Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(1)

13 String expreason[expreason] Explant ReasonStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 29 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Choice aesev[aesev] AE SeverityStyle: SimpleChoiceNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 MildBox 2: 2 ModerateBox 3: 3 Severe

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 Choice aerelatdev[aerelatdev] AE Relatedness to iFuseStyle: RelatednessNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Not relatedBox 2: 2 Possibly relatedBox 3: 3 Probably relatedBox 4: 4 Definitely related

52

Box 5: 5 Not applicableBox 6: 6 Unlikely to be related

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 Choice aerelatproc[aerelatproc] AE Relatedness to ProcedureStyle: RelatednessNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Not relatedBox 2: 2 Possibly relatedBox 3: 3 Probably relatedBox 4: 4 Definitely relatedBox 5: 5 Not applicableBox 6: 6 Unlikely to be related

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 Choice aerelatothSIJ[aerelatothSIJ] AE Relatedness to Other Trt for SIJ PainStyle: RelatednessNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Not relatedBox 2: 2 Possibly relatedBox 3: 3 Probably relatedBox 4: 4 Definitely relatedBox 5: 5 Not applicableBox 6: 6 Unlikely to be related

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: ecAEExisting()

18 Choice aerelatpre[aerelatpre] AE Relatedness to Pre-Exisiting CondStyle: RelatednessNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Not relatedBox 2: 2 Possibly relatedBox 3: 3 Probably relatedBox 4: 4 Definitely relatedBox 5: 5 Not applicableBox 6: 6 Unlikely to be related

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit:

53

Plate Exit: ecAEExisting()

19 String precond[precond] Previous Condition or ProcStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 20 Store: 40Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

20 String LCUser121[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

21 String LCDate121[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

22 String LCTime121[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 13 Store: 13Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

54

Plate # 122 (Adverse Event, p2)

6 Number AEID122[AEID] Adverse Event IDStyle: AE IDNeed: Essential Hidden: No Reason level: 0Legal: 301-340Help:

Display: 3 Store: 3Format: 3nn

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID122[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials122[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Check aedeath[aedeath] AE Lead to DeathStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Check aethreat[aethreat] AE Caused Life-Threatening ProblemStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

55

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Check aeperm[aeperm] AE Caused Permanent InjuryStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 Check aeprol[aeprol] AE Prolonged HospStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Check aeinterv[aeinterv] AE Required InterventionStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Check aenone[aenone] AE Consequences NoneStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

56

15 Check aenotreat[aenotreat] AE Not TreatmentStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 Check aemed[aemed] AE Medical TreatmentStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 1 fields if value equals 0Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(1)

17 String aemedtreat[aemedtreat] Medical Treatment ProvidedStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 32 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Check aeproc[aeproc] AE Procedure TreatmentStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 1 fields if value equals 0Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(1)

19 String aeproctreat[aeproctreat] Procedure Treatment ProvidedStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 32 Store: 55Format:

57

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

20 Check aesurg[aesurg] AE Surgical TreatmentStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 1 fields if value equals 0Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(1)

21 String aesurgtreat[aesurgtreat] Surgical Treatment ProvidedStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 32 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

22 Check aeoth[aeoth] AE Other TreatStyle: SimpleCheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 1 fields if value equals 0Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOtherSpecify(1)

23 String aeothtreat[aeothtreat] Other Treatment ProvidedStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 32 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

58

24 Choice aeout[aeout] AE OutcomeStyle: SimpleChoiceNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 ResolvedBox 2: 2 OngoingBox 3: 3 DeathBox 4: 4 Other

Skip: 1 fields if value equals 1-3Plate Enter: Field Enter:

Field Exit: Plate Exit: ecOngoing()

25 Date aelastevaldt[aelastevaldt] Date Last EvaluatedStyle: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

26 String aeoutother[aeoutother] AE Outcome Other (Spec)Style: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 27 Store: 55Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

27 String updcom[updcom] AE Update CommentStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 55 Store: 910Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

59

28 Date aeoutdt[aeoutdt] AE Outcome DateStyle: WIC DateNeed: Required Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

29 Choice invsae[invsae] Investigator Characterizes as SAEStyle: NY CheckNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 2 NoBox 2: 1 Yes

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

30 String saereas[saereas] SAE ReasonStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 45 Store: 777Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

31 Choice aerptirb[aerptirb] AE Reported to IRBStyle: YN CheckNeed: Optional Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 YesBox 2: 2 No

Skip: 1 fields if value equals 2Plate Enter: Field Enter:

Field Exit: Plate Exit:

32 Date aeirbrptdt[aeirbrptdt] AE IRB Report Date

60

Style: WIC DateNeed: Optional Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

33 String reasnotrep[reasnotrep] Reason Not ReportedStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 49 Store: 155Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

34 Check invrevae[invrevae] Investigator Has Reviewed Adv EventStyle: SimpleCheckNeed: Required Hidden: No Reason level: 0Legal: Help:

Check Off: 0 UncheckedCheck On: 1 Checked

Skip: 0 fields if value equals Plate Enter: ecInvOnly()Field Enter:

Field Exit: Plate Exit:

35 String LCUser122[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

36 String LCDate122[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal:

61

Help: Display: 12 Store: 12Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

37 String LCTime122[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 13 Store: 13Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 131 (Narrative)

6 Number narrID131[narrID] Narrative IDStyle: Narr IDNeed: Essential Hidden: No Reason level: 0Legal: 401-420Help:

Display: 3 Store: 3Format: 4nn

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID131[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials131[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3

62

Format: Mapping: To Upper

Skip: 0 fields if value equals Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Date narrdate[narrdate] Narrative DateStyle: VisitDateNeed: Required Hidden: No Reason level: 0Legal: 01/AUG/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Inherit

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 String narr[narr] NarrativeStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 71 Store: 2059Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 String LCUser131[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 String LCDate131[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

Mapping: None

63

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 String LCTime131[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 13 Store: 13Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 141 (Device Malfunction)

6 Number devmalID141[devmalID] Device Malfunction IDStyle: Dev Malf IDNeed: Essential Hidden: No Reason level: 0Legal: 501-510Help:

Display: 3 Store: 3Format: 5nn

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID141[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials141[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()

64

Field Enter: Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Date devmalfdt[devmalfdt] Device Malfunction DateStyle: WIC DateNeed: Required Hidden: No Reason level: 0Legal: 01/JAN/12-todayHelp:

Display: 9 Store: 9Format: dd/mmm/yy

Year: InheritImpute: Middle

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 String malfdet[malfdet] Malfunction Detailed DescStyle: SimpleStringNeed: Required Hidden: No Reason level: 0Legal: Help:

Display: 58 Store: 522Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Choice aemalf[aemalf] AE Related to MalfunctionStyle: NY CheckNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 2 NoBox 2: 1 Yes

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 String devmalcom[devmalcom] Device Malf CommentStyle: SimpleStringNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 58 Store: 406Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit:

65

Plate Exit:

13 String LCUser141[LCUser] Last Change UsernameStyle: LCUserNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 20Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 String LCDate141[LCDate] Last Change (Date)Style: LCDateNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 12 Store: 12Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 String LCTime141[LCTime] Last Change (Time)Style: LCTimeNeed: Optional Hidden: No Reason level: 0Legal: Help:

Display: 13 Store: 13Format:

Mapping: NoneSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit: ecSaveUser(); DataNotification()

Plate # 151 (VAS)

6 Choice visitseq151[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

66

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID151[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials151[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Number vaslb[vaslb] VAS Lower BackStyle: VASNeed: Required Hidden: No Reason level: 0Legal: 0-100Help:

Display: 3 Store: 3Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Number vassij[vassij] VAS Pelvis/buttocksStyle: VASNeed: Required Hidden: No Reason level: 0Legal: 0-100Help:

Display: 3 Store: 3Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

67

Plate # 152 (ODI)

6 Choice visitseq152[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID152[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials152[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Choice odi1[odi1] ODI 1Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

68

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice odi2[odi2] ODI 2Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Choice odi3[odi3] ODI 3Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 Choice odi4[odi4] ODI 4Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

69

Field Exit: Plate Exit:

13 Choice odi5[odi5] ODI 5Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Choice odi6[odi6] ODI 6Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 Choice odi7[odi7] ODI 7Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

70

16 Choice odi8[odi8] ODI 8Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 Choice odi9[odi9] ODI 9Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Choice odi10[odi10] ODI 10Style: ODI 0-5_99Need: Required Hidden: No Reason level: 0Legal: 0-5,98,99Help:

No Box: 999 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5Box 7: 99 Not answered

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

Plate # 154 (EQ5D)

71

6 Choice visitseq154[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID154[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials154[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Choice eq1[eq1] EQ5D-1Style: eq5dNeed: Required Hidden: No Reason level: 0Legal: 1-3Help:

No Box: 99 Not checkedBox 1: 1 1Box 2: 2 2Box 3: 3 3

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

72

10 Choice eq2[eq2] EQ5D-2Style: eq5dNeed: Required Hidden: No Reason level: 0Legal: 1-3Help:

No Box: 99 Not checkedBox 1: 1 1Box 2: 2 2Box 3: 3 3

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Choice eq3[eq3] EQ5D-3Style: eq5dNeed: Required Hidden: No Reason level: 0Legal: 1-3Help:

No Box: 99 Not checkedBox 1: 1 1Box 2: 2 2Box 3: 3 3

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 Choice eq4[eq4] EQ5D-4Style: eq5dNeed: Required Hidden: No Reason level: 0Legal: 1-3Help:

No Box: 99 Not checkedBox 1: 1 1Box 2: 2 2Box 3: 3 3

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Choice eq5[eq5] EQ5D-5Style: eq5dNeed: Required Hidden: No Reason level: 0Legal: 1-3Help:

No Box: 99 Not checkedBox 1: 1 1Box 2: 2 2Box 3: 3 3

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

73

14 Number eqvas[eqvas] EQ5D VASStyle: VASNeed: Required Hidden: No Reason level: 0Legal: 0-100Help:

Display: 3 Store: 3Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

Plate # 155 (Satisfaction)

6 Choice visitseq155[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID155[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials155[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

74

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Choice satisf155[satisf] Satisfaction w TreatmentStyle: SimpleChoiceNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Very dissatisfiedBox 2: 2 Somewhat dissatisfiedBox 3: 3 Somewhat satisfiedBox 4: 4 Very satisfied

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice ifagain[ifagain] Undergo iFuse AgainStyle: SimpleChoiceNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 Not haveBox 2: 2 Might haveBox 3: 3 Definitely have

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

Plate # 156 (Denver SIJ Questionnaire)

6 Choice visitseq156[visitseq] Visit SequenceStyle: FU Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

No Choice: 0 Not checkedChoice 1: 51 Phone 2.5yChoice 2: 52 Visit 3yChoice 3: 53 PHone 3.5yChoice 4: 54 Visit 4yChoice 5: 55 Phone 4.5yChoice 6: 56 Visit 5y

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID156[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)

75

Help: Site ID*1000 + ptIDDisplay: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit: DataNotification()

8 String initials156[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Choice dq1[dq1] DSIJQ Q1Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice dq2[dq2] DSIJQ Q2Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Choice dq3[dq3] DSIJQ Q3

76

Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 Choice dq4[dq4] DSIJQ Q4Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Choice dq5[dq5] DSIJQ Q5Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Choice dq6[dq6] DSIJQ Q6Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0

77

Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 Choice dq7[dq7] DSIJQ Q7Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 Choice dq8[dq8] DSIJQ Q8Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 Choice dq9[dq9] DSIJQ Q9Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals

78

Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Choice dq10[dq10] DSIJQ Q10Style: DSIJQNeed: Required Hidden: No Reason level: 0Legal: 0-5Help:

No Box: 99 Not checkedBox 1: 0 0Box 2: 1 1Box 3: 2 2Box 4: 3 3Box 5: 4 4Box 6: 5 5

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

Plate # 157 (Zung Dep Scale)

6 Number visitseq157[visitseq] Visit SequenceStyle: QOL Visit IDNeed: Essential Hidden: No Reason level: 0Legal: Help:

Display: 3 Store: 3Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

7 Number ID157[ID] Patient numberStyle: Patient IDNeed: Essential Hidden: No Reason level: 1Legal: $(ids)Help: Site ID*1000 + ptID

Display: 6 Store: 6Format:

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

8 String initials157[initials] Init ialsStyle: Init ialsNeed: Required Hidden: No Reason level: 0Legal: Help: Init ials of patient

Display: 3 Store: 3Format:

79

Mapping: To UpperSkip: 0 fields if value equals

Plate Enter: ecGetInitials()Field Enter:

Field Exit: ecGetInitials()Plate Exit: ecGetInitials()

9 Choice zung1[zung1] Zung 1Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

10 Choice zung2[zung2] Zung 2Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

11 Choice zung3[zung3] Zung 3Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

12 Choice zung4[zung4] Zung 4Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

80

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

13 Choice zung5[zung5] Zung 5Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

14 Choice zung6[zung6] Zung 6Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

15 Choice zung7[zung7] Zung 7Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

16 Choice zung8[zung8] Zung 8

81

Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

17 Choice zung9[zung9] Zung 9Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

18 Choice zung10[zung10] Zung 10Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

19 Choice zung11[zung11] Zung 11Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

82

Field Exit: Plate Exit:

20 Choice zung12[zung12] Zung 12Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

21 Choice zung13[zung13] Zung 13Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

22 Choice zung14[zung14] Zung 14Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

23 Choice zung15[zung15] Zung 15Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the time

83

Box 4: 4 Most of the timeSkip: 0 fields if value equals

Plate Enter: Field Enter:

Field Exit: Plate Exit:

24 Choice zung16[zung16] Zung 16Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

25 Choice zung17[zung17] Zung 17Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

26 Choice zung18[zung18] Zung 18Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

27 Choice zung19[zung19] Zung 19Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

84

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

28 Choice zung20[zung20] Zung 20Style: ZungNeed: Required Hidden: No Reason level: 0Legal: Help:

No Box: 0 Not checkedBox 1: 1 A little of the timeBox 2: 2 Some of the timeBox 3: 3 Good part of the timeBox 4: 4 Most of the time

Skip: 0 fields if value equals Plate Enter: Field Enter:

Field Exit: Plate Exit:

85