`Ͻ 1""2"2""2"22""SAS FILEROM3DATA DATA %A%A@8.0202M0WIN_PROWIN헷헷q8]%Ap8]]po >> <0%|"L\8(4444X4$4444T4 4444P44444L4444|4H4444x4D4444t4@4 444p4<4444l484444h444444d404444`4,4444\4(4444X4$4 4 4 4T 4 4 4 4 4P 4 4 4 4 4L 4 4 4 4| 4H 4 4 4 4x 4D 4 444t4@4 444p4p ?0/\2P2(2x.p<3403(`&T$-0)'|L0@0-(p,d40,(3.|D68-9-|H1<134L8@;:3t8:, 5  4 t 1h 4 1(  /  5 p 7d 4 .(  +  .  .x L +D  -  6  3 X -L  4  )  - d 5X $ 2 2+t-h@'8-0|pH%@"-4`4T5/-t%h<+4.34|D7< /4+\-P6&.l1d<'03* p#d<&$%$ |`@( ,$ggD UTf#Y: <8J\0=O_b@R3EFc&gC$H)]7>d1`[/AS"4X 'V%I MGL-Qe+(((PF  #&),/258;>ADGJMPSVY\_behknqtwz}@$8\8l8hX@8p\Dx<p `    T    H    0 l   0 p   4|HD@0l H \8tX> DATASTEPIDID of patientPtNAMEPTNAME: Patient full nameDATEDATE of survey completionMMDDYYMMDDYYAGEAGE of patientGENDERGender of patientSEXMDNAMEMDNAME: Patient"s doctor"s full namePAINPAIN: did patient have any pain todayYNDIAGNOSEPatient" diagnosisQ1Q1:feeling lump/fullness/throat stuck?NEVERQ2Q2:feeling lump etc 6mos or longer?YNQ3Q3:feeling occurs between meals?YNQ4Q4: When eating/drinking, hurt to swallow?RAREAQ5Q5: last 3m how often pain/discomfort in mid-chest?NEVERQ6Q6: had this chest pain 6mos or longer?YNQ7Q7: When chest pain, how often feel like burning?RAREAQ8Q8: last 3m how often heartburn in your chest?NEVERQ9Q9: had this heartburn 6mos or longer?YNQ10Q10: last 3m how often food/drinks stuck post-swallow?NEVERQ11Q11: food sticking associated with heartburn?RAREAQ12Q12: had this food sticking 6mos or longer?YNQ13Q13: last 3m how often uncomfortably full post-meal?NEVERQ14Q14: had uncomfortable fullness 6mos or longer?YNQ15Q15: last 3m how often unable to finish reg-size meals?NEVERQ16Q16: unable to finish reg-size meals 6mos or longer?YNQ17Q17: last 3m how often pain/burning in mid-abdomen?NEVERQ18Q18: had this pain/burning 6 months or longer?YNQ19Q19: mid-abd pain/burning come/go same day?RAREAQ20Q20: how severe mid-abd pain/burning?MILDQ21Q21: mid-abd pain/burning affected by eating?AFFECTQ22Q22: mid-abd pain/burning relieved by antacids?RAREAQ23Q22: pain/burning better or stop after a b/m or fart?RAREAQ24Q24: b/m change more or less @start of pain/burning?RAREAQ25Q25: softer/harder stool when pain/burning starteds?RAREAQ26Q26: last 3m how often had bothersome nausea?NEVERQ27Q27: nausea started > 6months ago?YNQ28Q28: last 3m how often did you vomit?NEVERQ29Q29: had vomit 6mos or longer?YNQ30Q30: made yourself vomit?RAREAQ31Q31:LastYr had episodic vomit days then stopped?RAREAQ32Q32: had at least 3 vomit episodes past year?YNQ33Q33: last 3mos food back up into mouth?NEVERQ34Q34: had food back into mouth 6mos or longer?YNQ35Q35: returned food stayed in mouth a while?RAREAQ36Q36: retching/heaving before food came into mouth?RAREAQ37Q37: how often vomit /sick to stomach @food regurgRAREAQ38Q38: food regurg stopped when food turned sour/acidicRAREAQ39Q39: last 3mos how often bothersome belching?NEVERQ40Q40: bothersome belching began >6mos ago?YNQ41Q41: last 3mos how often discomfort/pain in abdomen?NEVERQ42Q42: did you only have pain (not discomfort)?RAREAQ43Q43: this pain/discomf during menses/not oth times?YNNQ44Q44: how often did it limit/restrict daily activities?RAREAQ45Q45: had this discomfort/pain 6mos or longer?YNQ46Q46: how often it betterORstop after a b/m?RAREAQ47Q47: When discomf/pain started, MORE freq b/m?RAREAQ48Q48: When discomf/pain started, LESS freq b/m?RAREAQ49Q49: When discomf/pain started, LOOSER b/m?RAREAQ50Q50: When discomf/pain started, HARDER stools?RAREAQ51Q51: pain/discomf relieved by moving/chanQng positions?RAREAQ52Q52: last 3mos how often had <3 b/moves (0-2) a week?RAREAQ53Q53: last 3mos how often had hard/lumpy stools?RAREAQ54Q54: last 3mos how often did u strain during b/m?RAREAQ55Q55: last 3mos how often incomplete emptying b/m?RAREAQ56Q56: last 3mos how often sensation of stool blocked?RAREAQ57Q57: last 3mos how often press bottom 4 complete b/m?RAREAQ58Q58: last 3 mos how often difficult relax/let go when b/m?RAREAQ59Q59: Any constipation Sx in Q52-58 began >6mos ago?YNQ60Q60: last 3 mos how often had 4 or more bowel moves a day?RAREAQ61Q61: last 3 mos how often had loose/mushy/or watery stools?RAREAQ62Q62: last 3 mos at least stools loose/mushy/or watery?YNQ63Q63: freq loose/mushywatery stools began >6 mos ago?YNQ64Q63: last 3mos how often need rush to WC for a b/m?RAREAQ65Q65: last 3mos how often mucus/slime in your b/m?RAREAQ66Q66: last 3mos how often had bloating/distension?NEVERQ67Q67: bloating/distension began >6 months ago?YNQ68Q68: last 6m how often steady pain@mid/right side up abd?NEVERQ69Q69: Did this pain last 30 minutes or longer?RAREAQ70Q70: Did this pain build up to a steady, severe level?RAREAQ71Q71: pain go away completely between episodes?RAREAQ72Q72: pain curbs usual activities / leads to EM doc?RAREAQ73Q73: Have you had your Qbladder removed?YNQ74Q74: How often this pain since Qbladder removal?RAREAQ75Q75: last 3mos how often accidental leakage?NEVERQ76Q76: last 3mos what amount this leakage?LEAKQ77Q77: last year what composition this leakage?COMPQ78Q78: last3mar how often anal ache/pain/pressure?NEVERQ79Q79: How long did aching, pain or pressure last?ACHEQ80Q80: anorectal pain come & go same day?YNQ81Q81: anorectal ache/pain began >6mos ago?YNQ82Q82: last3mos how often noticed blood in stools?RAREAQ83Q83: last3mos how often noticed black stools?RAREAQ84Q84: last3mos how often vomited blood?RAREAQ85Q85: ever told by your doc u are anemic?YNQ86last3mos HowOften BodyTemp over 99F different days?RAREAQ87Q87: last3mos unintentionally lost over10pounds?YNQ88Q88: If 50+ had recent major change in bowel moves?YNNQ891Q891: parent/sibling Qag/stomach/colon cancer?YNQ892Q892: parent/sibling Ulcerative colitis or Crohns?YNQ893Q893: parent/sibling had Celiac disease?YNQ90Q90: past3mos how oft persistent voice hoarseness?RAREAQ91Q91: past3mos how oft persistent neck/throat pain?RAREAQ92Q92: past3mos how oft chest pain/heart problem?RAREAQ93Q93: past3mos how oft had difficulty swallowing?RAREA gt0g$>@p8]npp 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