Protocol - Personal Medical History of Allergies, Infectious Diseases, and Immunizations - Child
Description
This protocol is a proxy-administered personal health record from the American Health Information Management Association (AHIMA). The parent or guardian is asked to provide details on the child in the following categories: Birth, Health Log, Allergies/Drug Sensitivities, Infectious Disease, and Immunizations.
Specific Instructions
None
Availability
This protocol is freely available; permission not required for use.
Protocol
A. Birth
| Hospital |
| Height |
| Length |
| Doctor |
| Prenatal Problem |
| Apgar Score |
B. Health Log
| Date | Health Problem | Remarks |
| | | |
| | | |
| | | |
C. Allergies/Drug Sensitivities
| Allergy/Sensitivity Type | Reaction | Date Last Occurred | Treatment |
| | | | |
| | | | |
| | | | |
D. Infectious Disease
| Disease | Age | Date | Remarks |
| Chicken Pox | |||
| Measles | |||
| Rubella | |||
| Hepatitis | |||
| Pertussis/Whooping Cough | |||
| Pneumonia | |||
| Polio | |||
| Mumps | |||
| Scarlet Fever | |||
| Other |
E. Immunizations
| BOOSTER 1 | BOOSTER 2 | BOOSTER 3 | ||||
| Immunizations | AGE | DATE | AGE | DATE | AGE | DATE |
| Diphtheria | ||||||
| Pertussis/Whooping Cough | ||||||
| Tetanus | ||||||
| Smallpox | ||||||
| Typhoid | ||||||
| Rubella | ||||||
| Mumps | ||||||
| Measles | ||||||
| Tuberculosis | ||||||
| Hepatitis B | ||||||
| Other | ||||||
Personnel and Training Required
None
Equipment Needs
None
Requirements
| Requirement Category | Required |
|---|---|
| Major equipment | No |
| Specialized training | No |
| Specialized requirements for biospecimen collection | No |
| Average time of greater than 15 minutes in an unaffected individual | No |
Mode of Administration
Proxy-administered questionnaire
Lifestage
Infant, Child, Adolescent
Participants
Infants, children, and teenagers, aged under 18 years old.
Selection Rationale
The American Health Information Management Associations (AHIMAs) My Personal Health Record (MyPHR) protocol is a national program used by several state health information management associations in community-based settings.
Language
English, Spanish
Standards
| Standard | Name | ID | Source |
|---|---|---|---|
| Logical Observation Identifiers Names and Codes (LOINC) | Hx allerg infect immun child proto | 62894-1 | LOINC |
| Human Phenotype Ontology | Allergy | HP:0012393 | HPO |
| caDSR Form | PhenX PX161601 - Personal Medical History Of Allergies Infect | 6929406 | caDSR Form |
Derived Variables
None
Process and Review
Not applicable.
Protocol Name from Source
My Personal Health Record (MyPHR), Child PHR Form, 2006
Source
American Health Information Management Association (AHIMA). My Personal Health Record (MyPHR). Child PHR Form 2006. Sections B,C, D, F, G.
General References
None
Protocol ID
161601
Variables
Export Variables| Variable Name | Variable ID | Variable Description | dbGaP Mapping | |
|---|---|---|---|---|
| PX161601_Allergy/Sensitivity1_Date_Last_Occurred_Month | ||||
| PX161601030103 | Allergy/Sensitivity 1 - Date Last Occurred - Month | N/A | ||
| PX161601_Allergy/Sensitivity1_Date_Last_Occurred_Year | ||||
| PX161601030105 | Allergy/Sensitivity 1 - Date Last Occurred - Year | N/A | ||
| PX161601_Allergy/Sensitivity1_Type | ||||
| PX161601030101 | Allergy/Sensitivity 1 - Type (include more | N/A | ||
| PX161601_Allergy/Sensitivity2_Date_Last_Occurred_Month | ||||
| PX161601030203 | Allergy/Sensitivity 2 - Date Last Occurred - Month | N/A | ||
| PX161601_Allergy/Sensitivity2_Date_Last_Occurred_Year | ||||
| PX161601030205 | Allergy/Sensitivity 2 - Date Last Occurred - Year | N/A | ||
| PX161601_Allergy/Sensitivity2_Type | ||||
| PX161601030201 | Allergy/Sensitivity 2 - Type (include more | N/A | ||
| PX161601_Allergy/Sensitivity3_Date_Last_Occurred_Month | ||||
| PX161601030303 | Allergy/Sensitivity 3 - Date Last Occurred - Month | N/A | ||
| PX161601_Allergy/Sensitivity3_Date_Last_Occurred_Year | ||||
| PX161601030305 | Allergy/Sensitivity 3 - Date Last Occurred - Year | N/A | ||
| PX161601_Allergy/Sensitivity3_Type | ||||
| PX161601030301 | Allergy/Sensitivity 3 - Type (include more | N/A | ||
| PX161601_Birth_Apgar_Score | ||||
| PX161601010600 | Birth Apgar Score | N/A | ||
| PX161601_Birth_Doctor | ||||
| PX161601010400 | Birth Doctor | N/A | ||
| PX161601_Birth_Length | ||||
| PX161601010300 | Birth Length | Variable Mapping | ||
| PX161601_Birth_Weight | ||||
| PX161601010200 | Birth Weight | Variable Mapping | ||
| PX161601_Chicken_Pox_Age | ||||
| PX161601040101 | Chicken Pox - Age | N/A | ||
| PX161601_Chicken_Pox_Date_Day | ||||
| PX161601040103 | Chicken Pox - Date - Day | N/A | ||
| PX161601_Chicken_Pox_Remarks | ||||
| PX161601040105 | Chicken Pox - Remarks | N/A | ||
| PX161601_Diphtheria_Booster1_Age | ||||
| PX161601050100 | Diphtheria Booster 1 Age | N/A | ||
| PX161601_Diphtheria_Booster1_Date_Day | ||||
| PX161601050202 | Diphtheria Booster 1 Date - Day | N/A | ||
| PX161601_Diphtheria_Booster2_Age | ||||
| PX161601050300 | Diphtheria Booster 2 Age | N/A | ||
| PX161601_Diphtheria_Booster2_Date_Day | ||||
| PX161601050402 | Diphtheria Booster 2 Date - Day | N/A | ||
| PX161601_Diphtheria_Booster3_Age | ||||
| PX161601050500 | Diphtheria Booster 3 Age | N/A | ||
| PX161601_Diphtheria_Booster3_Date_Day | ||||
| PX161601050602 | Diphtheria Booster 3 Date - Day | N/A | ||
| PX161601_Health_Problem1_Date_Month | ||||
| PX161601020102 | Health Problem 1 - Date - Month | N/A | ||
| PX161601_Health_Problem1_Date_Year | ||||
| PX161601020104 | Health Problem 1 - Date - Year | N/A | ||
| PX161601_Health_Problem2_Date_Day | ||||
| PX161601020203 | Health Problem 2 - Date - Day | N/A | ||
| PX161601_Health_Problem2_Remarks | ||||
| PX161601020205 | Health Problem 2 - Remarks (e.g., more | N/A | ||
| PX161601_Health_Problem2_Type | ||||
| PX161601020201 | Health Problem 2 - Type | N/A | ||
| PX161601_Health_Problem3_Date_Month | ||||
| PX161601020302 | Health Problem 3 - Date - Month | N/A | ||
| PX161601_Health_Problem3_Date_Year | ||||
| PX161601020304 | Health Problem 3 - Date - Year | N/A | ||
| PX161601_Hepatitis_B_Booster1_Age | ||||
| PX161601140100 | Hepatitis B Booster 1 Age | N/A | ||
| PX161601_Hepatitis_B_Booster1_Date_Day | ||||
| PX161601140202 | Hepatitis B Booster 1 Date - Day | N/A | ||
| PX161601_Hepatitis_B_Booster2_Age | ||||
| PX161601140300 | Hepatitis B Booster 2 Age | N/A | ||
| PX161601_Hepatitis_B_Booster2_Date_Day | ||||
| PX161601140402 | Hepatitis B Booster 2 Date - Day | N/A | ||
| PX161601_Hepatitis_B_Booster3_Age | ||||
| PX161601140500 | Hepatitis B Booster 3 Age | N/A | ||
| PX161601_Hepatitis_B_Booster3_Date_Day | ||||
| PX161601140602 | Hepatitis B Booster 3 Date - Day | N/A | ||
| PX161601_Hepatitis_Date_Month | ||||
| PX161601040402 | Hepatitis - Date - Month | N/A | ||
| PX161601_Hepatitis_Date_Year | ||||
| PX161601040404 | Hepatitis - Date - Year | N/A | ||
| PX161601_Measles_Booster1_Age | ||||
| PX161601120100 | Measles Booster 1 Age | N/A | ||
| PX161601_Measles_Booster1_Date_Day | ||||
| PX161601120202 | Measles Booster 1 Date - Day | N/A | ||
| PX161601_Measles_Booster2_Age | ||||
| PX161601120300 | Measles Booster 2 Age | N/A | ||
| PX161601_Measles_Booster2_Date_Day | ||||
| PX161601120402 | Measles Booster 2 Date - Day | N/A | ||
| PX161601_Measles_Booster3_Age | ||||
| PX161601120500 | Measles Booster 3 Age | N/A | ||
| PX161601_Measles_Booster3_Date_Day | ||||
| PX161601120602 | Measles Booster 3 Date - Day | N/A | ||
| PX161601_Measles_Date_Month | ||||
| PX161601040202 | Measles - Date - Month | N/A | ||
| PX161601_Measles_Date_Year | ||||
| PX161601040204 | Measles - Date - Year | N/A | ||
| PX161601_Mumps_Booster1_Age | ||||
| PX161601110100 | Mumps Booster 1 Age | N/A | ||
| PX161601_Mumps_Booster1_Date_Day | ||||
| PX161601110202 | Mumps Booster 1 Date - Day | N/A | ||
| PX161601_Mumps_Booster2_Age | ||||
| PX161601110300 | Mumps Booster 2 Age | N/A | ||
| PX161601_Mumps_Booster2_Date_Day | ||||
| PX161601110402 | Mumps Booster 2 Date - Day | N/A | ||
| PX161601_Mumps_Booster3_Age | ||||
| PX161601110500 | Mumps Booster 3 Age | N/A | ||
| PX161601_Mumps_Booster3_Date_Day | ||||
| PX161601110602 | Mumps Booster 3 Date - Day | N/A | ||
| PX161601_Mumps_Date_Month | ||||
| PX161601040802 | Mumps - Date - Month | N/A | ||
| PX161601_Mumps_Date_Year | ||||
| PX161601040804 | Mumps - Date - Year | N/A | ||
| PX161601_Other_Booster1_Age | ||||
| PX161601150100 | Other Booster 1 Age | N/A | ||
| PX161601_Other_Booster1_Date_Day | ||||
| PX161601150202 | Other Booster 1 Date - Day | N/A | ||
| PX161601_Other_Booster2_Age | ||||
| PX161601150300 | Other Booster 2 Age | N/A | ||
| PX161601_Other_Booster2_Date_Day | ||||
| PX161601150402 | Other Booster 2 Date - Day | N/A | ||
| PX161601_Other_Booster3_Age | ||||
| PX161601150500 | Other Booster 3 Age | N/A | ||
| PX161601_Other_Booster3_Date_Day | ||||
| PX161601150602 | Other Booster 3 Date - Day | N/A | ||
| PX161601_Other_Date_Month | ||||
| PX161601041002 | Other - Date - Month | N/A | ||
| PX161601_Other_Date_Year | ||||
| PX161601041004 | Other - Date - Year | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Age | ||||
| PX161601040501 | Pertussis/Whooping Cough - Age | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Booster1_Age | ||||
| PX161601060100 | Pertussis/Whooping Cough Booster 1 Age | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Booster1_Date_Day | ||||
| PX161601060202 | Pertussis/Whooping Cough Booster 1 Date - Day | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Booster2_Age | ||||
| PX161601060300 | Pertussis/Whooping Cough Booster 2 Age | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Booster2_Date_Day | ||||
| PX161601060402 | Pertussis/Whooping Cough Booster 2 Date - Day | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Booster3_Age | ||||
| PX161601060500 | Pertussis/Whooping Cough Booster 3 Age | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Booster3_Date_Day | ||||
| PX161601060602 | Pertussis/Whooping Cough Booster 3 Date - Day | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Date_Day | ||||
| PX161601040503 | Pertussis/Whooping Cough - Date - Day | N/A | ||
| PX161601_Pertussis/Whooping_Cough_Remarks | ||||
| PX161601040505 | Pertussis/Whooping Cough - Remarks | N/A | ||
| PX161601_Pneumonia_Date_Month | ||||
| PX161601040602 | Pneumonia - Date - Month | N/A | ||
| PX161601_Pneumonia_Date_Year | ||||
| PX161601040604 | Pneumonia - Date - Year | N/A | ||
| PX161601_Polio_Age | ||||
| PX161601040701 | Polio - Age | N/A | ||
| PX161601_Polio_Date_Day | ||||
| PX161601040703 | Polio - Date - Day | N/A | ||
| PX161601_Polio_Remarks | ||||
| PX161601040705 | Polio - Remarks | N/A | ||
| PX161601_Rubella_Age | ||||
| PX161601040301 | Rubella - Age | N/A | ||
| PX161601_Rubella_Booster1_Age | ||||
| PX161601100100 | Rubella Booster 1 Age | N/A | ||
| PX161601_Rubella_Booster1_Date_Day | ||||
| PX161601100202 | Rubella Booster 1 Date - Day | N/A | ||
| PX161601_Rubella_Booster2_Age | ||||
| PX161601100300 | Rubella Booster 2 Age | N/A | ||
| PX161601_Rubella_Booster2_Date_Day | ||||
| PX161601100402 | Rubella Booster 2 Date - Day | N/A | ||
| PX161601_Rubella_Booster3_Age | ||||
| PX161601100500 | Rubella Booster 3 Age | N/A | ||
| PX161601_Rubella_Booster3_Date_Day | ||||
| PX161601100602 | Rubella Booster 3 Date - Day | N/A | ||
| PX161601_Rubella_Date_Day | ||||
| PX161601040303 | Rubella - Date - Day | N/A | ||
| PX161601_Rubella_Remarks | ||||
| PX161601040305 | Rubella - Remarks | N/A | ||
| PX161601_Scarlet_Fever_Age | ||||
| PX161601040901 | Scarlet Fever - Age | N/A | ||
| PX161601_Scarlet_Fever_Date_Day | ||||
| PX161601040903 | Scarlet Fever - Date - Day | N/A | ||
| PX161601_Scarlet_Fever_Remarks | ||||
| PX161601040905 | Scarlet Fever - Remarks | N/A | ||
| PX161601_Smallpox_Booster1_Age | ||||
| PX161601080100 | Smallpox Booster 1 Age | N/A | ||
| PX161601_Smallpox_Booster1_Date_Day | ||||
| PX161601080202 | Smallpox Booster 1 Date - Day | N/A | ||
| PX161601_Smallpox_Booster2_Age | ||||
| PX161601080300 | Smallpox Booster 2 Age | N/A | ||
| PX161601_Smallpox_Booster2_Date_Day | ||||
| PX161601080402 | Smallpox Booster 2 Date - Day | N/A | ||
| PX161601_Smallpox_Booster3_Age | ||||
| PX161601080500 | Smallpox Booster 3 Age | N/A | ||
| PX161601_Smallpox_Booster3_Date_Day | ||||
| PX161601080602 | Smallpox Booster 3 Date - Day | N/A | ||
| PX161601_Tetanus_Booster1_Age | ||||
| PX161601070100 | Tetanus Booster 1 Age | N/A | ||
| PX161601_Tetanus_Booster1_Date_Day | ||||
| PX161601070202 | Tetanus Booster 1 Date - Day | N/A | ||
| PX161601_Tetanus_Booster2_Age | ||||
| PX161601070300 | Tetanus Booster 2 Age | N/A | ||
| PX161601_Tetanus_Booster2_Date_Day | ||||
| PX161601070402 | Tetanus Booster 2 Date - Day | N/A | ||
| PX161601_Tetanus_Booster3_Age | ||||
| PX161601070500 | Tetanus Booster 3 Age | N/A | ||
| PX161601_Tetanus_Booster3_Date_Day | ||||
| PX161601070602 | Tetanus Booster 3 Date - Day | N/A | ||
| PX161601_Tuberculosis_Booster1_Age | ||||
| PX161601130100 | Tuberculosis Booster 1 Age | N/A | ||
| PX161601_Tuberculosis_Booster1_Date_Day | ||||
| PX161601130202 | Tuberculosis Booster 1 Date - Day | N/A | ||
| PX161601_Tuberculosis_Booster2_Age | ||||
| PX161601130300 | Tuberculosis Booster 2 Age | N/A | ||
| PX161601_Tuberculosis_Booster2_Date_Day | ||||
| PX161601130402 | Tuberculosis Booster 2 Date - Day | N/A | ||
| PX161601_Tuberculosis_Booster3_Age | ||||
| PX161601130500 | Tuberculosis Booster 3 Age | N/A | ||
| PX161601_Tuberculosis_Booster3_Date_Day | ||||
| PX161601130602 | Tuberculosis Booster 3 Date - Day | N/A | ||
| PX161601_Typhoid_Booster1_Age | ||||
| PX161601090100 | Typhoid Booster 1 Age | N/A | ||
| PX161601_Typhoid_Booster1_Date_Day | ||||
| PX161601090202 | Typhoid Booster 1 Date - Day | N/A | ||
| PX161601_Typhoid_Booster2_Age | ||||
| PX161601090300 | Typhoid Booster 2 Age | N/A | ||
| PX161601_Typhoid_Booster2_Date_Day | ||||
| PX161601090402 | Typhoid Booster 2 Date - Day | N/A | ||
| PX161601_Typhoid_Booster3_Age | ||||
| PX161601090500 | Typhoid Booster 3 Age | N/A | ||
| PX161601_Typhoid_Booster3_Date_Day | ||||
| PX161601090602 | Typhoid Booster 3 Date - Day | N/A | ||
Infectious Diseases and Immunity
Measure Name
Personal Medical History of Allergies, Infectious Diseases, and Immunizations
Release Date
November 12, 2010
Definition
This measure is a questionnaire to collect information on a participant's personal medical history of allergies, infectious diseases, and immunizations.
Purpose
This measure can be used to establish a respondent's medical history of allergies, selected infectious diseases, and immunizations.
Keywords
Infectious disease, Immunizations, Allergies, personal history, Medical History, American Health Information Management Association, AHIMA, My Personal Health Record, MyPHR, Infectious Diseases and Immunity
Measure Protocols
| Protocol ID | Protocol Name |
|---|---|
| 161601 | Personal Medical History of Allergies, Infectious Diseases, and Immunizations - Child |
| 161602 | Personal History of Allergies, Infectious Diseases, and Immunizations - Adult |