ID

16535

Description

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

Keywords

Versions (2)
  1. 7/22/16 7/22/16 -
  2. 11/17/16 11/17/16 -
Uploaded on

July 22, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Medical History (General): CRF Wisconsin Madison

English

Medical History (General): CRF Wisconsin Madison

1 forms  
Header
Description

Header

PI Name
Description

PI Name

Data type

text

Protocol or IRB Number
Description

Protocol or IRB Number

Data type

integer

Protocol Short Title
Description

Protocol Short Title

Data type

text

Subject Initials
Description

Subject Initials

Data type

text

Subject ID
Description

Subject ID

Data type

integer

Date
Description

Date

Data type

date

Medical History (General)
Description

Medical History (General)

Insert body system being inquired about
Description

Body System

Data type

text

Diagnosed condition
Description

Diagnosed condition

Data type

boolean

Diagnosis/Condition/Surgery
Description

Diagnosis/Condition/Surgery

Data type

text

Onset Date or Year
Description

Onset Date or Year

Data type

integer

Current Problem
Description

Current Problem

Data type

boolean

Other (specify)
Description

Other (specify)

Diagnosed condition
Description

Diagnosed condition

Data type

boolean

Diagnosis/Condition/Surgery
Description

Diagnosis/Condition/Surgery

Data type

text

Onset Date Or Year
Description

Onset Date Or Year

Data type

integer

Current Problem
Description

Current Problem

Data type

boolean

Additional Notes
Description

Additional Notes

Data type

text

Medical History Not Obtained
Description

Medical History Not Obtained

Data type

boolean

Medical History Obtained By
Description

Medical History Obtained By

Data type

text

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Similar models

Medical History (General): CRF Wisconsin Madison

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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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