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1 |
[record_id] |
Record ID |
text |
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2 |
[participant_id_a6270f] |
Participant Name |
text, Required, Identifier |
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3 |
[participant_id_2] |
Participant ID |
text, Required, Identifier |
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4 |
[aud_diagnosis_requirement] |
AUD Diagnosis Requirement
AUD निदान आवश्यकता
Do you have a diagnosis of Alcohol Use Disorder (AUD), or are you a healthy individual without an AUD diagnosis?
क्या आपको शराब उपयोग विकार (AUD) का निदान हुआ है, या आप एक स्वस्थ व्यक्ति हैं जिसे शराब उपयोग विकार का निदान नहीं हुआ है?
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dropdown, Required, Identifier| 1 | Only Alcohol Use Disorder (AUD) patient - केवल शराब उपयोग विकार (AUD) रोगी | | 2 | Alcohol Use Disorder (AUD) patient + Anxiety + mood disorders - शराब उपयोग विकार (AUD) रोगी + चिंता + मूड विकार | | 3 | Healthy volunteer - स्वस्थ स्वयंसेवक |
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5 |
[aud_diagnosis_requirement_2] |
As a healthy volunteer, do you consider yourself a social drinker?(do you consume alcohol socially)
एक स्वस्थ स्वयंसेवक के रूप में, क्या आप खुद को सामाजिक रूप से शराब पीने वाला मानते/मानती हैं? (क्या आप सामाजिक रूप से शराब का सेवन करते/करती हैं?)
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yesno, Required, Identifier |
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6 |
[gen_health] |
General Health |
radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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8 |
[head_health] |
Head Health |
radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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10 |
[sensory] |
Eyes/Physical (sensory below)
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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12 |
[nose_physical_sensory_below] |
Nose/Physical (sensory below)
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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14 |
[mouth_teeth_gum] |
Mouth/Teeth/Gum
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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16 |
[tongue_physical_sensory_below] |
Tongue/Physical (sensory below)
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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18 |
[throat] |
Throat
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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20 |
[lymph_nodes] |
Lymph Nodes
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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22 |
[cardiovascular] |
Cardiovascular
|
radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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24 |
[pulmonary] |
Pulmonary
|
radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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26 |
[gastrointestinal] |
Gastrointestinal
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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28 |
[integumentary_skin] |
Integumentary/Skin
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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30 |
[genital_urinary_system] |
Genital/Urinary System
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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32 |
[musculoskeletal_physical_motor_and_sensory_below] |
Musculoskeletal /Physical (motor and sensory below)
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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34 |
[endocrine] |
Endocrine
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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36 |
[hematologic] |
Hematologic
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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38 |
[immunologic_infectious_disease] |
Immunologic & Infectious Disease
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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40 |
[immunologic_infectious_disease_2] |
Psychiatric/ Mental status
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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42 |
[neuro] |
Neuro - Sensation-Touch
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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44 |
[neuro_2] |
Neuro - Sensation-Graphesthesia
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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46 |
[neuro_3] |
Neuro -Sensation- Stereognosis
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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48 |
[neuro_4] |
Neuro- Sensation- Proprioception & Point Discrimination
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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50 |
[neuro_5] |
Neuro - Sensation- Temperature
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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52 |
[neuro_6] |
Neuro- Sensation- Pain
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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54 |
[neuro_7] |
Neuro -Motor-Gait
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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56 |
[neuro_8] |
Neuro - Motor- Reflexes
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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58 |
[olfactory_cranial_nerve_i] |
Olfactory Cranial Nerve I
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radio, Required| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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60 |
[olfactory_cranial_nerve_i_2] |
Optic Cranial Nerve II
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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62 |
[cranial_nerve_iii_iv_vi] |
Cranial Nerve III, IV, VI
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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64 |
[trigeminal_nerve_v] |
Trigeminal Nerve V
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radio, Required| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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66 |
[facial_nerve_vii] |
Facial Nerve VII
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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68 |
[vestibulocochlear_nerve_viii] |
Vestibulocochlear Nerve VIII
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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70 |
[glossopharyngeal_vagus_ix_x] |
Glossopharyngeal & Vagus IX, X
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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72 |
[spinal_accessory_nerve_xii] |
Spinal Accessory Nerve XII
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radio| 1 | Normal | | 2 | Abnormal | | 3 | Not Evaluated |
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74 |
[diagnosis] |
Diagnosis: Neurological evaluation shows:
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radio| 1 | Cranial nerves are normal | | 2 | Cranial nerves are abnormal |
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75 |
[screening_survey_exclusion_criteria_physical_neuro_complete] |
Section Header: Form Status
Complete?
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dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
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