Patient Identification
Item
Please give Patient ID composed of Study site Nr and Patient Nr
integer
C1269815 (UMLS CUI [1])
Date of phone contact
Item
Date of phone contact
date
C0011008 (UMLS CUI [1])
Safety laboratory results
Item
Safety laboratory results of visit 14 have been completed. If yes, please inform your patient of the results.
boolean
C1254595 (UMLS CUI [1,1])
C1269689 (UMLS CUI [1,2])
Safety laboratory results
Item
Laboratory results are without findings, no additional visit required
boolean
C1254595 (UMLS CUI [1,1])
C1269689 (UMLS CUI [1,2])
Safety laboratory result
Item
One or more laboratory results are abnormal: this is an AE, please arrange for an additional visit, note the date of appointment below and complete the AE report form.
boolean
C1254595 (UMLS CUI [1,1])
C1269689 (UMLS CUI [1,2])
Appointment date
Item
Please fill in the date of the additional appointment
date
C0585085 (UMLS CUI [1])
Date
Item
Date of completion of this form
date
C0011008 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])