ID

16535

Beschrijving

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Medical History (General). Case Report Form (CRF)/Source Document templates were created for University of Wisconsin-Madison researchers. These templates are consistent with the FDA's CDASH (Clinical Data Acquisition Standards Harmonization) standards. The CDASH standards identify those elements that should be captured on a Case Report Form (CRF). The forms serve only as templates, and must be edited to meet the study data collection needs as described in the protocol.

Link

https://ictr.wisc.edu/CaseReptTempt

Trefwoorden

  1. 22-07-16 22-07-16 -
  2. 17-11-16 17-11-16 -
Geüploaded op

22 juli 2016

DOI

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Licentie

Creative Commons BY-NC 3.0

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Medical History (General): CRF Wisconsin Madison

Medical History (General): CRF Wisconsin Madison

Header
Beschrijving

Header

PI Name
Beschrijving

PI Name

Datatype

text

Protocol or IRB Number
Beschrijving

Protocol or IRB Number

Datatype

integer

Protocol Short Title
Beschrijving

Protocol Short Title

Datatype

text

Subject Initials
Beschrijving

Subject Initials

Datatype

text

Subject ID
Beschrijving

Subject ID

Datatype

integer

Date
Beschrijving

Date

Datatype

date

Medical History (General)
Beschrijving

Medical History (General)

Insert body system being inquired about
Beschrijving

Body System

Datatype

text

Diagnosed condition
Beschrijving

Diagnosed condition

Datatype

boolean

Diagnosis/Condition/Surgery
Beschrijving

Diagnosis/Condition/Surgery

Datatype

text

Onset Date or Year
Beschrijving

Onset Date or Year

Datatype

integer

Current Problem
Beschrijving

Current Problem

Datatype

boolean

Other (specify)
Beschrijving

Other (specify)

Diagnosed condition
Beschrijving

Diagnosed condition

Datatype

boolean

Diagnosis/Condition/Surgery
Beschrijving

Diagnosis/Condition/Surgery

Datatype

text

Onset Date Or Year
Beschrijving

Onset Date Or Year

Datatype

integer

Current Problem
Beschrijving

Current Problem

Datatype

boolean

Additional Notes
Beschrijving

Additional Notes

Datatype

text

Medical History Not Obtained
Beschrijving

Medical History Not Obtained

Datatype

boolean

Medical History Obtained By
Beschrijving

Medical History Obtained By

Datatype

text

Similar models

Medical History (General): CRF Wisconsin Madison

Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header
PI Name
Item
PI Name
text
Protocol or IRB Number
Item
Protocol or IRB Number
integer
Protocol Short Title
Item
Protocol Short Title
text
Subject Initials
Item
Subject Initials
text
Subject ID
Item
Subject ID
integer
Date
Item
Date
date
Item Group
Medical History (General)
Body System
Item
Insert body system being inquired about
text
Diagnosed condition
Item
Diagnosed condition
boolean
Diagnosis/Condition/Surgery
Item
Diagnosis/Condition/Surgery
text
Onset Date or Year
Item
Onset Date or Year
integer
Current Problem
Item
Current Problem
boolean
Item Group
Other (specify)
Diagnosed condition
Item
Diagnosed condition
boolean
Diagnosis/Condition/Surgery
Item
Diagnosis/Condition/Surgery
text
Onset Date Or Year
Item
integer
Current Problem
Item
Current Problem
boolean
Additional Notes
Item
Additional Notes
text
Medical History Not Obtained
Item
Medical History Not Obtained
boolean
Medical History Obtained By
Item
Medical History Obtained By
text

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