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Medical History Form: UIC Quality Improvement CRF

1 forms  
General Information
Description

General Information

Protocol Title
Description

Protocol Title

Data type

text

Site Number
Description

Site Number

Data type

integer

Subject ID
Description

Subject ID

Data type

integer

Visit Date
Description

Visit Date

Data type

date

Study Visit
Description

Study Visit

Data type

integer

Medical History
Description

Medical History

1. HEENT
Description

1. HEENT

Data type

boolean

HEENT: UNK (unknown)
Description

HEENT

Data type

boolean

HEENT: If yes, Describe (include onset date)
Description

HEENT

Data type

text

HEENT
Description

HEENT

Data type

text

2. Respiratory
Description

2. Respiratory

Data type

boolean

Respiratory: UNK
Description

Respiratory

Data type

boolean

Respiratory: If yes, Describe (include onset date)
Description

Respiratory

Data type

text

Respiratory
Description

Respiratory

Data type

text

3. Cardiovascular
Description

3. Cardiovascular

Data type

boolean

Cardiovascular: UNK
Description

Cardiovascular

Data type

boolean

Cardiovascular: If yes, Describe (include onset date)
Description

Cardiovascular

Data type

text

Cardiovascular
Description

Cardiovascular

Data type

text

4. Gastrointestinal/Hepatic
Description

4. Gastrointestinal/Hepatic

Data type

boolean

Gastrointestinal/Hepatic: UNK
Description

Gastrointestinal/Hepatic

Data type

boolean

Gastrointestinal/Hepatic: If yes, Describe (include onset date)
Description

Gastrointestinal/Hepatic

Data type

text

Gastrointestinal/Hepatic
Description

Gastrointestinal/Hepatic

Data type

text

5. Genitourinary
Description

5. Genitourinary

Data type

boolean

Genitourinary: UNK
Description

Genitourinary

Data type

boolean

Genitourinary: If Yes, Describe (include onset date)
Description

Genitourinary

Data type

text

Genitourinary
Description

Genitourinary

Data type

text

6. Musculoskeletal
Description

6. Musculoskeletal

Data type

boolean

Musculoskeletal: UNK
Description

Musculoskeletal

Data type

boolean

Musculoskeletal: If Yes, Describe (include onset date)
Description

Musculoskeletal

Data type

text

Musculoskeletal
Description

Musculoskeletal

Data type

text

7. Neurological
Description

7. Neurological

Data type

boolean

Neurological: UNK
Description

Neurological

Data type

boolean

Neurological: If yes, Describe (include onset date)
Description

Neurological

Data type

text

Neurological
Description

Neurological

Data type

text

8. Endocrine-Metabolic
Description

8. Endocrine-Metabolic

Data type

boolean

Endocrine-Metabolic: UNK
Description

Endocrine-Metabolic

Data type

boolean

Endocrine-Metabolic: If Yes, Describe (include onset date)
Description

Endocrine-Metabolic

Data type

text

Endocrine-Metabolic
Description

Endocrine-Metabolic

Data type

text

9. Hematologic/Lymphatic
Description

9. Hematologic/Lymphatic

Data type

boolean

Hematologic/Lymphatic: UNK
Description

Hematologic/Lymphatic

Data type

boolean

Hematologic/Lymphatic: If Yes, Describe (include onset date)
Description

Hematologic/Lymphatic

Data type

text

Hematologic/Lymphatic
Description

Hematologic/Lymphatic

Data type

text

10. Dermatologic
Description

10. Dermatologic

Data type

boolean

Dermatologic: UNK
Description

Dermatologic

Data type

boolean

Dermatologic: If Yes, Describe (include onset date)
Description

Dermatologic

Data type

text

Dermatologic
Description

Dermatologic

Data type

text

11. Psychiatric
Description

11. Psychiatric

Data type

boolean

Psychiatric: UNK
Description

Psychiatric

Data type

boolean

Psychiatric: If Yes, Describe (include onset date)
Description

Psychiatric

Data type

text

Psychiatric
Description

Psychiatric

Data type

text

12. Allergy
Description

12. Allergy

Data type

boolean

Allergy: UNK
Description

Allergy: UNK

Data type

boolean

Allergy: If Yes, Describe (include onset date)
Description

Allergy

Data type

text

Allergy
Description

Allergy

Data type

text

13. Surgical Procedure
Description

13. Surgical Procedure

Data type

boolean

Surgical Procedure: UNK
Description

Surgical Procedure

Data type

boolean

Surgical Procedure: If Yes, Describe (include onset date)
Description

Surgical Procedure

Data type

text

Surgical Procedure
Description

Surgical Procedure

Data type

text

14. Other (specify)
Description

14. Other (specify)

Data type

boolean

Other (specify)
Description

Other (specify)

Data type

boolean

Other (specify): UNK
Description

Other (specify)

Data type

boolean

Other (specify): If Yes, Describe (include onset date)
Description

Other (specify)

Data type

text

Other (specify)
Description

Other (specify)

Data type

text

Completed by (initials)
Description

Completed by (initials)

Data type

text

Date completed
Description

Date completed

Data type

date

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Similar models

Medical History Form: UIC Quality Improvement CRF

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
General Information
Protocol Title
Item
Protocol Title
text
Site Number
Item
Site Number
integer
Subject ID
Item
Subject ID
integer
Visit Date
Item
Visit Date
date
Study Visit
Item
Study Visit
integer
Item Group
Medical History
1. HEENT
Item
1. HEENT
boolean
HEENT
Item
HEENT: UNK (unknown)
boolean
HEENT
Item
HEENT: If yes, Describe (include onset date)
text
Item
HEENT
text
HEENT
Code List
HEENT
CL Item
Current (1)
CL Item
Resolved (2)
2. Respiratory
Item
2. Respiratory
boolean
Respiratory
Item
Respiratory: UNK
boolean
Respiratory
Item
Respiratory: If yes, Describe (include onset date)
text
Item
Respiratory
text
Respiratory
Code List
Respiratory
CL Item
Current (1)
CL Item
Resolved (2)
3. Cardiovascular
Item
3. Cardiovascular
boolean
Cardiovascular
Item
Cardiovascular: UNK
boolean
Cardiovascular
Item
Cardiovascular: If yes, Describe (include onset date)
text
Item
Cardiovascular
text
Cardiovascular
Code List
Cardiovascular
CL Item
Current (1)
CL Item
Resolved (2)
4. Gastrointestinal/Hepatic
Item
4. Gastrointestinal/Hepatic
boolean
Gastrointestinal/Hepatic
Item
Gastrointestinal/Hepatic: UNK
boolean
Gastrointestinal/Hepatic
Item
Gastrointestinal/Hepatic: If yes, Describe (include onset date)
text
Item
Gastrointestinal/Hepatic
text
Gastrointestinal/Hepatic
Code List
Gastrointestinal/Hepatic
CL Item
Current (1)
CL Item
Resolved (2)
5. Genitourinary
Item
5. Genitourinary
boolean
Genitourinary
Item
Genitourinary: UNK
boolean
Genitourinary
Item
Genitourinary: If Yes, Describe (include onset date)
text
Item
Genitourinary
text
Genitourinary
Code List
Genitourinary
CL Item
Current (1)
CL Item
Resolved (2)
6. Musculoskeletal
Item
6. Musculoskeletal
boolean
Musculoskeletal
Item
Musculoskeletal: UNK
boolean
Musculoskeletal
Item
Musculoskeletal: If Yes, Describe (include onset date)
text
Item
Musculoskeletal
text
Musculoskeletal
Code List
Musculoskeletal
CL Item
Current (1)
CL Item
Resolved (2)
7. Neurological
Item
7. Neurological
boolean
Neurological
Item
Neurological: UNK
boolean
Neurological
Item
Neurological: If yes, Describe (include onset date)
text
Item
Neurological
text
Neurological
Code List
Neurological
CL Item
Current (1)
CL Item
Resolved (2)
8. Endocrine-Metabolic
Item
8. Endocrine-Metabolic
boolean
Endocrine-Metabolic
Item
Endocrine-Metabolic: UNK
boolean
Endocrine-Metabolic
Item
Endocrine-Metabolic: If Yes, Describe (include onset date)
text
Item
Endocrine-Metabolic
text
Endocrine-Metabolic
Code List
Endocrine-Metabolic
CL Item
Current (1)
CL Item
Resolved (2)
9. Hematologic/Lymphatic
Item
9. Hematologic/Lymphatic
boolean
Hematologic/Lymphatic
Item
Hematologic/Lymphatic: UNK
boolean
Hematologic/Lymphatic
Item
Hematologic/Lymphatic: If Yes, Describe (include onset date)
text
Item
Hematologic/Lymphatic
text
Hematologic/Lymphatic
Code List
Hematologic/Lymphatic
CL Item
Current (1)
CL Item
Resolved (2)
10. Dermatologic
Item
10. Dermatologic
boolean
Dermatologic
Item
Dermatologic: UNK
boolean
Dermatologic
Item
Dermatologic: If Yes, Describe (include onset date)
text
Item
Dermatologic
text
Dermatologic
Code List
Dermatologic
CL Item
Current (1)
CL Item
Resolved (2)
11. Psychiatric
Item
11. Psychiatric
boolean
Psychiatric
Item
Psychiatric: UNK
boolean
Psychiatric
Item
Psychiatric: If Yes, Describe (include onset date)
text
Item
Psychiatric
text
Psychiatric
Code List
Psychiatric
CL Item
Current (1)
CL Item
Resolved (2)
12. Allergy
Item
12. Allergy
boolean
Allergy: UNK
Item
Allergy: UNK
boolean
Allergy
Item
Allergy: If Yes, Describe (include onset date)
text
Item
Allergy
text
Allergy
Code List
Allergy
CL Item
Current (1)
CL Item
Resolved (2)
13. Surgical Procedure
Item
13. Surgical Procedure
boolean
Surgical Procedure
Item
Surgical Procedure: UNK
boolean
Surgical Procedure
Item
Surgical Procedure: If Yes, Describe (include onset date)
text
Item
Surgical Procedure
text
Surgical Procedure
Code List
Surgical Procedure
CL Item
Current (1)
CL Item
Resolved (2)
14. Other (specify)
Item
14. Other (specify)
boolean
Other (specify)
Item
Other (specify)
boolean
Other (specify)
Item
Other (specify): UNK
boolean
Other (specify)
Item
Other (specify): If Yes, Describe (include onset date)
text
Item
Other (specify)
text
Other (specify)
Code List
Other (specify)
CL Item
Current (1)
CL Item
Resolved (2)
Completed by (initials)
Item
Completed by (initials)
text
Date completed
Item
Date completed
date
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