Patient ID (Combine PRACID, Sudy # & Patient serial #)
PATIENT ID
Obturation 1:Yes 0:No
Specialty: 1:General, 5:Endodontist
DDS:Gender 1:Male 2:Female
DDS:Hispanic 1-y 0-n
Administered by 1:phone 0:paper
Today visit date: month
Today visit date: year
4Q.1 Fear-appt today: 1:no|2:little|3:quite|4:very much
4Q.2 Tx outcome will turn out: 1:very good|2:good|3:fair|4:poor
4Q.4 Pain meds past 7 days: 1:yes 0:no
4Q.5a Pain quality: none 1:yes 0:no
4Q.5b Pain quality: dull: 1:yes 0:no
4Q.5c Pain quality: sharp: 1:yes 0:no
4Q.5d Pain quality: aching: 1:yes 0:no
4Q.5e Pain quality: throbbing: 1:yes 0:no
4Q.5f Pain quality: burning: 1:yes 0:no
4Q.5g Pain quality: shooting: 1:yes 0:no
4Q.5h Pain quality: electric: 1:yes 0:no
4Q.6a Pain quality: spontaneous: 1:yes 0:no
4Q.6b Pain quality: provoked: 1:yes 0:no
4Q.7a Pain never gets worse: 1:yes 0:no
4Q.7b Pain gets worse by itself: 1:yes 0:no
4Q.7c Pain gets worse by bite/chew: 1:yes 0:no
4Q.7d Pain gets worse by cold/hot: 1:yes 0:no
4Q.7e Pain gets worse by stress: 1:yes 0:no
4Q.8 Present time pain, 0:none-10:worst
4Q.9 Pain intensity past wk, 0:none-10:worst
4Q.10 Avg pain intensity past wk, 0:none-10:worst
4Q.11 #days pain kept from act past wk, trunc at 5
4Q.12 Pain interfere daily activities past wk: 0:none to 9
4Q.13 Pain interfere social/fam act past wk, 0:none to 9
4Q.14 Pain interfere worK past wk, 0:none to 9
4Q.15 Pain present 8+hrs/day,15+ days/mo,in last 3+mos: 1:yes 0:no
4Q.16 Pain >1 area in last 3 months: 4day/wk: 1:yes 0:no
4Q.17 Smoked 100 cigs in life: 1:yes 0:no
4Q.18 Smoke cigs now: 1:yes 0:no
4Q.19 Average number cigs/day
4Q.20 Diabetes or high blood sugar: 1:yes 0:no
4Q.21 Gender: 1=male 2=female
4Q.22 Age in years
4Q23. Ethnicity: 1=Hispanic 2=not Hispanic
4Q25. Dental ins/3rd party coverage: 1:yes 0:no
4Q26. Annual income:1=<$10K|2=$10K-$29K|3=$30K-49K|4>=$50K
4Q27. Education: 1=<hs|2=hs|3=some coll|4=college|5=Advanced/grad
5Q1. Tooth number for RCT
5Q2. Radiolucency (periradicular/apical): 1:yes 0:no
5Q3. Tender to percussion: 1:yes 0:no
5Q4. Tender to biting pressure: 1:yes 0:no
5Q5. Respond to cold testing: 1:yes 0:no
5Q6. Cold testing response longer than adjacent teeth: 1:yes 0:no
5Q7. Greatest probing depth, mm
5Q8. Location greatest probing depth: 1=mesial|2=distal|3=buccal|4=lingual
7D1.Q1. Bleeding in pulp chamber: 1:yes 0:no
7D1.Q2a. Pulpectomy: 1:yes 0:no
7D1.Q2b. Cleaning/shaping: 1:yes 0:no
7D1.Q2c. Obturation: 1:yes 0:no
7D1.Q3b. Not negotiable canal: 1:yes 0:no
7D1.Q3d. Instrument in canal: 1:yes 0:no
7D1.Q3e. Filing past apex: 1:yes 0:no
7D1.Q3f. None of the above: 1:none of the above 0:N/A
7D1.Q4. Harder than usual RCT: 1:yes 0:no
7D1.Q5. LA quality during RCT: 1:excellent|2:adequate|3:marginal/painful
7D1.Q6. Draining sinus tract: (fistula) 1:yes 0:no
7D1.Q7. Swelling: 1:yes 0:no
7D1.Q8a. 2nd inj same type/location: 1:yes 0:no
7D1.Q8b. 2nd inj same type/slighty diff location: 1:yes 0:no
7D1.Q8d. PDL inj: 1:yes 0:no
7D1.Q8e. Intraosseous inj other than PDL: 1:yes 0:no
7D1.Q8f. Intrapulpal: 1:yes 0:no
7D1.Q8g. None of the above: 1:yes 0:no
7D1.Q9. Persistent pain likely in 6 mo: 1=not|2=slight|3=mod|4=high
7D1.Q11. Tooth obturated,RCT completed today: 1:yes 0:no
7D1.Q13. Tx stopped, not amenable to RCT: 1:yes 0:no
9P1Q1.Pain intensity during RCT: 0 to 6, trunc
9P1Q2. How numb felt during RCT: 1:not enough|2:enough|3:too numb
9P1Q3.Fear vs actual: 1=no fear|2=better|3=as feared or worse
11P1Q2. Any pain med in last 7 days: 1:yes 0:No
11P1Q3. Rating pain right now, 0-8, trunc
11P1Q4. Intensity worst pain in past wk, 0-10
11P1Q5. Average intensity pain past wk, 0-8, trunc
11P1Q6. Pain interfering daily activities past wk, 0-7, trunc
11P1Q7. Pain interfere social/fam activities past wk, 0-7, trunc
11P1Q8. Pain interfere w/ability work past wk, 0-7, trunc
11P1Q9. # days pain kept from usual act past wk, trunc at 4
11P1Q10. Swelling: 1=none|2=little|3=some|4=a lot
11P1Q11. Fear vs actual: 1=no fear|2=better|3=as feared|4=worse
7D2Q1. Bleeding in the pulp chamber: 1:yes 0:no
7D2Q2a Pulpectomy: 1:yes 0:no
7D2Q2b cleaning/shaping: 1:yes 0:no
7D2Q2c. Obturation: 1:yes 0:no
7D2Q3a. Perforation: 1:yes 0:no
7D2Q3b. Not negotiable canal: 1:yes 0:no
7D2Q3c. Incomplete Tx: 1:yes 0:no
7D2Q3f. None of the above: 1:none of the above 0:N/A
7D2Q4. Harder than usual RCT: 1:yes 0:no
7D2Q5.Quality during RCT: 1:excellent|2:adequate|3:marginal to painful
7D2Q8. Diff block anesth technique: 1:yes 0:no
7D2Q8. Itraosseous inj other than PDL: 1:yes 0:no
7D2Q8. None of the above: 1:yes 0:no
7D2Q9. Persistent pain likely 6 mo: 1=not|2=slight|3=mod to high
7D2Q10. Pt feigning pain for narcotic rx: 1=no|2=possibly|3=yes
7D2Q12. Perm restoration placed in access: 1:yes 0:no
7D2Q13. Tx stopped, not amenable to RCT: 1:yes 0:no
9P2Q1. Intensity of pain during RCT, 0-4, trunc
9P2Q2. How numb felt during RCT 1:not enough|2:enough|3:too numb
9P2Q3. Fear vs actual: 1=no fear|2=better|3=as feared or worse
11P2Q1.Days pain during past wk, 0-3, trunc
11P2Q2. Any pain med in last 7 days: 1:yes 0:No
11P2Q3.Rating pain right now, 0-2, trunc
11P2Q4.Intensity worst pain past wk, 0-9, trunc
11P2Q5.Average intensity pain past wk, 0-6, trunc
11P2Q6.Pain interfere daily act past wk, 0:none,1:any
11P2Q7.Pain interfere social/fam act past wk, 0:none,1:any
11P2Q8.Pain interfere w/ability work past wk, 0:none,1:any
11P2Q9. # days pain kept from usual act past wk 0:none,1:any
11P2Q10.Swelling: 1=none|2=little|3=some/a lot
11P2Q11.Fear vs actual:1=no fear|2=better|3=as feared/worse
Form 14. Opioid(s) within 8 hrs: 1:Yes
Form 14. Non-opoid pre-op within 48 hours: 1:Yes
Form 14. Nitrous oxide: 1:Yes
Form 14. General anesthesia (any/all drugs): 1:Yes
Form 14. None of the above: 1:Yes
PRACTITIONER ID
DPBRN Administrative region
US State of residence, NA=SK
12Q1.Pain rating now, 0-4, trunc
12Q2. any pain med in last 7 days: 1:yes 0:no
12Q3. Pain present 8+hrs/day,15+ days/mo,in last 3+mos: 1:yes 0:no
12Q4. How many days ago did pain go away: 1:still here 2:disappeared
12Q5.A1. Additional RCT: 1:yes 0:no
12Q5.A3. Additional x-rays: 1:yes 0:no
12Q5.B1. Suppl pain medication: 1:yes 0:no
12Q5.B2. Antibiotics: 1:yes 0:no
12Q5.C. Medical dr. appt: 1:yes 0:no
12Q5.E. None of the above: 1:yes
13Q2. Any pain med in last mo: 1:yes 0:no
13Q3. Rating present time pain 0-4, trunc
13Q4. Intensity worst pain last mo, 0-5,trunc
13Q5. Intensity average last mo, 0-5, trunc
13Q6. Number days pain kept from activities last mo
13Q7. Pain interfere w/daily act last mo, 0-2, trunc
13Q8. Pain interfere social/family act last mo 0:none,1:any
13Q9. Pain interfere ability work last mo, 0:none, 1:any
13Q10. Pain present 8+hrs/day,15+ days/mo,in last 3+mos: 1:yes 0:no
13Q12. RCT experience-fear vs actual:1=no fear|2=better|3=as feared|4=worse
13Q13A1 Additional RCT in last 3 mo 1:yes 0:no
13Q13A3 Additional X-rays: 1:yes 0:no
13Q13B1 Additional pain medication: 1:yes 0:no
13Q13B2 Antibiotics: 1:yes 0:no
13Q13C Medical Dr appt: 1:yes 0:no
13Q13E None of the above: 1:yes
Study 17 participant
Study 18 participant
Decade dentist graduated
4Q24.Race: 1=White|2=Black|4=Asian|6=Other
13Q1.# days pain last month:0, 1:1-15, 2:>15