Information:
Error:
ID
16965
Description
ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Physical Exam. QIP Case Report Forms, UIC Quality Improvement CRF, Office of the Vice Chancellor for Research. Center for Clinical and Translational Science, UIC University of Illinois at Chicago.
Link
http://research.uic.edu/qip/toolbox/case-report-forms-crf
Keywords
Versions (1)
- 8/17/16 8/17/16 -
Uploaded on
August 17, 2016
DOI
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License
Creative Commons BY-NC 3.0
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Physical Exam: UIC Quality Improvement CRF
Physical Exam: UIC Quality Improvement CRF
- StudyEvent: ODM
Similar models
Physical Exam: UIC Quality Improvement CRF
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Protocol Title
Item
Protocol Title
text
Site Number
Item
Site Number
integer
Subject ID
Item
Subject ID
integer
Visit Date
Item
Visit Date
date
CL Item
Screening (1)
CL Item
Baseline (2)
CL Item
Visit (specification) (3)
Study Visit
Item
Specification of Visit
text
Completion/Early Termination
Item
Completion/Early Termination
boolean
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
General Appearance
Item
General Appearance: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
HEENT
Item
HEENT: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Neck
Item
Neck: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Chest and Lungs
Item
Chest and Lungs: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Cardiovascular
Item
Cardiovascular: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Abdomen
Item
Abdomen: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Genitourinary
Item
Genitourinary: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Rectal
Item
Rectal: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Musculoskeletal
Item
Musculoskeletal: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Lymph Nodes
Item
Lymph Nodes: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Extremities/Skin
Item
Extremities/Skin: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Neurological
Item
Neurological: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
Other
Item
Other: Please specify
text
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not Examined (3)
Other
Item
Other: If abnormal, please describe
text
CL Item
Yes (1)
CL Item
No (2)
CL Item
NA (3)
Clinician Signature
Item
Clinician Signature
text
Date Completed
Item
Date Completed
date
Clinician Printed Name
Item
Clinician Printed Name
text