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Relapse Evaluation DIMAT-MS, Relapsing Remitting Multiple Sclerosis NCT02461069Relapse Evaluation

1 forms  
Confirmation of Relapse
Description

Confirmation of Relapse

Start date of relapse symptoms
Description

Start date of relapse symptoms

Data type

date

Alias
UMLS CUI [1,1]
C0035020
UMLS CUI [1,2]
C0808070
Confirmation of the relapse?
Description

Confirmation of the relapse

Data type

boolean

Alias
UMLS CUI [1,1]
C0035020
UMLS CUI [1,2]
C0521091
If yes, date of relapse confirmation:
Description

If relapse confirmed, date of relapse confirmation:

Data type

text

Alias
UMLS CUI [1,1]
C0035020
UMLS CUI [1,2]
C0521091
UMLS CUI [1,3]
C0011008
Treatment of Relapse
Description

Treatment of Relapse

no treatment
Description

no treatment

Data type

boolean

Alias
UMLS CUI [1,1]
C0035020
UMLS CUI [1,2]
C0332155
Plasmapheresis / Immunoadsorption
Description

Plasmapheresis / Immunoadsorption

Data type

boolean

Alias
UMLS CUI [1]
C0398341
UMLS CUI [2]
C0032134
If Plasmapheresis / Immunoadsorption= yes, enter number of cycles
Description

enter number of cycles

Data type

integer

other treatment
Description

other treatment

Data type

text

Alias
UMLS CUI [1]
C0087111
Intravenous Steroid Treatment
Description

Intravenous Steroid Treatment

Alias
UMLS CUI-1
C0149783
Treatment Start Date
Description

Treatment Begin Date

Data type

date

Alias
UMLS CUI [1]
C3173309
Treatment End Date
Description

Treatment End Date

Data type

date

Alias
UMLS CUI [1]
C1531784
Dose
Description

Medication Dose

Data type

float

Measurement units
  • g/day
Alias
UMLS CUI [1]
C3174092
g/day
Signature
Description

Signature

Date
Description

Investigator Signature Date

Data type

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Signature Investigator
Description

Signature Investigator

Data type

text

Alias
UMLS CUI [1]
C2346576
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Similar models

Relapse Evaluation DIMAT-MS, Relapsing Remitting Multiple Sclerosis NCT02461069Relapse Evaluation

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Confirmation of Relapse
Start date of relapse symptoms
Item
Start date of relapse symptoms
date
C0035020 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Confirmation of the relapse
Item
Confirmation of the relapse?
boolean
C0035020 (UMLS CUI [1,1])
C0521091 (UMLS CUI [1,2])
date of relapse confirmation
Item
If yes, date of relapse confirmation:
text
C0035020 (UMLS CUI [1,1])
C0521091 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
no treatment
Item
no treatment
boolean
C0035020 (UMLS CUI [1,1])
C0332155 (UMLS CUI [1,2])
Plasmapheresis / Immunoadsorption
Item
Plasmapheresis / Immunoadsorption
boolean
C0398341 (UMLS CUI [1])
C0032134 (UMLS CUI [2])
enter number of cycles
Item
If Plasmapheresis / Immunoadsorption= yes, enter number of cycles
integer
other treatment
Item
other treatment
text
C0087111 (UMLS CUI [1])
Item Group
Intravenous Steroid Treatment
C0149783 (UMLS CUI-1)
Treatment Begin Date
Item
Treatment Start Date
date
C3173309 (UMLS CUI [1])
Treatment End Date
Item
Treatment End Date
date
C1531784 (UMLS CUI [1])
Medication Dose
Item
Dose
float
C3174092 (UMLS CUI [1])
Item Group
Signature
Investigator Signature Date
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Signature Investigator
Item
Signature Investigator
text
C2346576 (UMLS CUI [1])
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