crf3a_version |
|
radio |
CRF3 Version Completed |
1, Unversioned ; 2, 1.0 ; 3, 1.1 ; 4, 1.2 ; 5, 1.3 ; 6, 1.4 ; 7, 1.5 ; 8, 1.6 ; 9, 2.0 |
crf3a_consent_date |
|
text |
Date of consent |
|
crf3a_visit_date |
|
text |
Date of consultation |
|
crf3a_visit |
|
radio |
With which research visit does this clinical visit align? |
3_months_arm_1, 3 months visit ; 12_months_arm_1, 12 months visit |
crf3a_rest_spo2_done |
Resting observations |
radio |
a) Pulse Oximetry (SpO2) |
1, Yes ; 0, No |
crf3a_rest_hr_done |
|
radio |
b) Heart rate |
1, Yes ; 0, No |
crf3a_rest_bp_done |
|
radio |
c) Blood pressure |
1, Yes ; 0, No |
crf3a_rest_temp_done |
|
radio |
d) Temperature |
1, Yes ; 0, No |
crf3a_rest_height_done |
|
radio |
e) Height (cm) |
1, Yes ; 0, No |
crf3a_rest_weight_done |
|
radio |
f) Weight (kg) |
1, Yes ; 0, No |
crf3a_rest_spo2 |
|
text |
a) Resting Pulse Oximetry (SpO2): |
|
crf3a_rest_hr |
|
text |
b) Resting heart rate: |
|
crf3a_rest_bp_sys |
|
text |
c) Resting blood pressure (systolic): |
|
crf3a_rest_bp_dia |
|
text |
c) Resting blood pressure (diastolic): |
|
crf3a_rest_temp |
|
text |
d) Temperature: |
|
crf3a_rest_height |
|
text |
e) Height (cm): |
|
crf3a_rest_weight |
|
text |
f) Weight (kg): |
|
crf3a_base_cxr_done |
Basic investigations |
radio |
a) Chest XR |
1, Completed ; 2, Not done |
crf3a_base_ecg_done |
|
radio |
b) ECG |
1, Completed ; 2, Not done |
crf3a_base_cxr |
|
radio |
a) Chest XR result: |
1, Normal ; 2, Extensive persistent changes >1/3 lung involvement ; 3, Suggestive of fibrotic lung disease ; 4, Indeterminate ; 5, Other |
crf3a_ecg |
|
radio |
b) ECG result: |
1, Sinus rhythm ; 2, Atrial fibrillation/flutter ; 3, ST segment/T wave changes ; 4, RBBB ; 5, LBBB |
crf3a_base_ecg_hr |
|
text |
b) ECG heart rate: |
|
crf3a_outcome_fup |
Clinical review Outcome |
radio |
1. Further follow up |
1, Yes ; 0, No |
crf3a_outcome_ras |
|
radio |
2. Referred to another speciality |
1, Yes ; 0, No |
crf3a_outcome_rtc |
|
radio |
3. Referred to a tertiary centre for specialised care |
1, Yes ; 0, No |
crf3a_outcome_rpc |
|
radio |
4. Referred/discharged to palliative care |
1, Yes ; 0, No |
crf3a_outcome_rmhs |
|
radio |
5. Referred to mental health services including IAPT |
1, Yes ; 0, No |
crf3a_outcome_rrh |
|
radio |
6. Referred to Rehabilitation |
1, Yes ; 0, No |
crf3a_outcome_rdt |
|
radio |
7. Referred to Dietician or similar |
1, Yes ; 0, No |
crf3a_outcome_rsss |
|
radio |
8. Referred to a Stop Smoking Service |
1, Yes ; 0, No |
crf3a_outcome_dis |
|
radio |
9. Discharged from clinical review |
1, Yes ; 0, No |
crf3a_tier |
|
radio |
4. Tier allocation |
1, Tier 1 ; 2, Tier 2 |
crf3a_blood_done |
Blood tests |
yesno |
Were any blood tests requested? |
1, Yes ; 0, No |
crf3a_blood_fbc |
|
radio |
FBC |
1, Yes ; 0, No |
crf3a_blood_ue |
|
radio |
U&Es |
1, Yes ; 0, No |
crf3a_blood_egfr |
|
radio |
eGFR |
1, Yes ; 0, No |
crf3a_blood_lfts |
|
radio |
LFTs |
1, Yes ; 0, No |
crf3a_blood_crp |
|
radio |
CRP |
1, Yes ; 0, No |
crf3a_blood_bp |
|
radio |
Bone profile |
1, Yes ; 0, No |
crf3a_blood_25oh |
|
radio |
25-Hydroxyvitamin D (25-OH) |
1, Yes ; 0, No |
crf3a_blood_bnp |
|
radio |
BNP/Pro-NT BNP |
1, Yes ; 0, No |
crf3a_blood_trop |
|
radio |
Troponin |
1, Yes ; 0, No |
crf3a_blood_ddim |
|
radio |
D Dimer |
1, Yes ; 0, No |
crf3a_blood_fib |
|
radio |
Fibrinogen |
1, Yes ; 0, No |
crf3a_blood_inr |
|
radio |
INR |
1, Yes ; 0, No |
crf3a_blood_fer |
|
radio |
Ferritin |
1, Yes ; 0, No |
crf3a_blood_hba1c |
|
radio |
HbA1C |
1, Yes ; 0, No |
crf3a_blood_lp |
|
radio |
Lipid profile (non-fasting) |
1, Yes ; 0, No |
crf3a_blood_covid19 |
|
radio |
SARS-Cov-2 Serology |
1, Yes ; 0, No |
crf3a_link_routine_blood |
|
yesno |
If any blood tests performed, please enter results in the Laboratory Results Collection Log - Routine blood tests |
1, Yes ; 0, No |
crf3a_link_add_blood_sars |
|
yesno |
If Sars-CoV-2 Serology performed, please enter results in the Laboratory Results Collection Log - Additional blood tests |
1, Yes ; 0, No |
crf3a_inv_resp |
Additional investigations/procedures |
checkbox |
Respiratory |
1, Spirometry ; 2, Full pulmonary function tests ; 3, Fractional exhaled nitric oxide (FeNO) ; 4, Nijmegen questionnaire ; 5, Incremental shuttle walk test (ISWT) ; 6, Six-minute walk test ; 7, Cardio-pulmonary exercise test ; 8, CT chest with contrast ; 9, HRCT ; 10, CTPA ; 11, Pulmonary perfusion scan |
crf3a_inv_cardiac |
|
checkbox |
Cardiac |
1, Cardiac MRI ; 2, Echocardiogram ; 3, 24/48 hrs tape ; 4, Right heart catheterisation ; 5, Coronary angiogram/CT angiogram ; 6, Cardiac perfusion scan |
crf3a_inv_haema |
|
checkbox |
Haematological |
1, Thyroid function tests ; 2, Blood borne viruses (BBV) screen ; 3, Haematinics |
crf3a_link_add_blood_haema |
|
yesno |
If Thyroid Function Tests or Haematinics (Haematological Profile) performed, please enter results in the Laboratory Results Collection Log - Additional Blood Tests.If BBV Screen performed, please enter results in the Laboratory Results Collection Log - Immunological Profile. |
1, Yes ; 0, No |
crf3a_inv_renal |
|
checkbox |
Renal |
1, USS abdomen ; 2, USS Kidneys ; 3, CT abdomen/pelvis ; 4, Urinalysis ; 5, Urine albumin: creatinine ratio ; 6, Urine protein: creatinine ratio ; 7, Renal biopsy |
crf3a_link_blood_urine |
|
yesno |
If Urinalysis, Urine albumin : creatinine ratio or Urine protein : creatinine ratio performed, please enter results in the Laboratory Results Collection Log - Urine Profile. |
1, Yes ; 0, No |
crf3a_inv_immu |
|
checkbox |
Immunological |
1, Vasculitis screen ; 2, Complements factors ; 3, Immunoglobulins ; 4, Rheumatoid factor/Anti-CCP |
crf3a_link_blood_immun |
|
yesno |
If any immunological procedures performed, please enter results in the Laboratory Results Collection Log - Immunological Profile. |
1, Yes ; 0, No |
crf3a_inv_neuro |
|
checkbox |
Neurology/Mental health |
1, CT brain ; 2, MRI brain ; 3, Nerve conduction studies ; 4, Mini-International Neuro-psychiatric Interview (M.I.N.I.) ; 5, Columbia-Suicide Severity Rating Scale ; 6, Sleep Condition Indicator |
crf3a_inv_other |
|
notes |
Other, please specify |
|
crf3a_quest |
Questionnaires |
checkbox |
Questionnaires completed |
1, MRC dyspnoea scale ; 2, EQ-5D-5L ; 3, Generalised Anxiety Disorder Assessment (GAD-7) ; 4, Patient Health Questionnaire (PHQ-9) ; 5, Sarcopenia screen (SARC-F) ; 6, General Practice Physical Activity Questionnaire (GPPAQ) ; 7, Dyspnoea-12 ; 8, Fatigue (FACIT) ; 9, Brief Pain Inventory (BPI) ; 10, Post-Traumatic Stress Disorder (PTSD) checklist (PCL-5) ; 11, Nottingham extended activity of daily living (NEADL) |
crf3a_quest_mrc |
|
yesno |
1. Have you completed a MRC dyspnoea scale form? |
1, Yes ; 0, No |
crf3a_quest_eq5d5l |
|
yesno |
2. Have you completed a EQ-5D-5L form? |
1, Yes ; 0, No |
crf3a_quest_gad7 |
|
yesno |
3. Have you completed a GAD-7 form? |
1, Yes ; 0, No |
crf3a_quest_phq9 |
|
yesno |
4. Have you completed a PHQ-9 form? |
1, Yes ; 0, No |
crf3a_quest_sarcf |
|
yesno |
5. Have you completed a SARC-F form? |
1, Yes ; 0, No |
crf3a_quest_gppaq |
|
yesno |
6. Have you completed a GPPAQ form? |
1, Yes ; 0, No |
crf3a_quest_dys12 |
|
yesno |
7. Have you completed a Dyspnoea-12 form? |
1, Yes ; 0, No |
crf3a_quest_facit |
|
yesno |
8. Have you completed a FACIT form? |
1, Yes ; 0, No |
crf3a_quest_bpi |
|
yesno |
9. Have you completed a BPI form? |
1, Yes ; 0, No |
crf3a_quest_pcl5 |
|
yesno |
10. Have you completed a PCL-5 form? |
1, Yes ; 0, No |
crf3a_quest_neadl |
|
yesno |
11. Have you completed a NEADL form? |
1, Yes ; 0, No |
crf3a_inv_quest |
Investigator completed assessments |
checkbox |
Assessments completed |
1, Montreal Cognitive Assessment (MoCA) ; 2, Clinical Frailty Scale |
crf3a_quest_moca |
|
yesno |
1. Have you completed a MoCA form? |
1, Yes ; 0, No |
crf3a_quest_rcfs |
|
yesno |
2. Have you completed a Rockwood Clinical Frailty Scale form? |
1, Yes ; 0, No |
crf3a_pft_done |
Pulmonary function tests |
yesno |
Have you completed a PFTs form? |
1, Yes ; 0, No |
crf3a_echo_date |
Additional investigations/procedures results |
text |
Echocardiogram: Date performed |
|
crf3a_echo_right |
|
radio |
Echocardiogram: Results - Right ventricle |
1, Normal ; 2, Mild dysfunction ; 3, Moderate dysfunction ; 4, Severe dysfunction ; 5, Unable to visualise |
crf3a_echo_left |
|
radio |
Echocardiogram: Results - Left ventricle |
1, Normal ; 2, Mild dysfunction ; 3, Moderate dysfunction ; 4, Severe dysfunction ; 5, Unable to visualise |
crf3a_echo_pap |
|
text |
Echocardiogram: Estimated PAP |
|
crf3a_tape_done |
|
yesno |
24/48 hours tape: Symptom diary completed |
1, Yes ; 0, No |
crf3a10_tape_date |
|
text |
24/48 hours tape: Date performed |
|
crf3a_tape_finding |
|
checkbox |
24/48 hours tape: Findings |
1, Sinus rhythm ; 2, Atrial flutter/fibrillation ; 3, Significant bradycardia ; 4, Significant tachycardia ; 5, Heart block ; 6, Sinus pause > 3 seconds ; 7, Burden of ectopic > 10% |
crf3a10_tape_heartblock |
|
text |
24/48 hours tape: Heart block details |
|
crf3a_nijm_date |
|
text |
Nijmegen questionnaire: Date performed |
|
crf3a_nijm_result |
|
text |
Nijmegen questionnaire: Result |
|
crf3a_cpet_date |
|
text |
Cardio-pulmonary exercise test: Date performed |
|
crf3a_cpet_result |
|
text |
Cardio-pulmonary exercise test: Result (Peak Vo2) |
|
crf3a_feno_date |
|
text |
Fractional exhaled nitric oxide (FeNO): Date performed |
|
crf3a_feno_result |
|
text |
Fractional exhaled nitric oxide (FeNO): Result |
|
crf3a_6mwt_done |
6 Minute Walk Test |
yesno |
Have you completed a Walk Test form? |
1, Yes ; 0, No |