ID

16878

Beschreibung

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Medical History Form. 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

Stichworte

Versionen (1)
  1. 11.08.16 11.08.16 -
Hochgeladen am

11. August 2016

DOI

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Medical History Form: UIC Quality Improvement CRF

Englisch

Medical History Form: UIC Quality Improvement CRF

1 Formulare  
General Information
Beschreibung

General Information

Protocol Title
Beschreibung

Protocol Title

Datentyp

text

Site Number
Beschreibung

Site Number

Datentyp

integer

Subject ID
Beschreibung

Subject ID

Datentyp

integer

Visit Date
Beschreibung

Visit Date

Datentyp

date

Study Visit
Beschreibung

Study Visit

Datentyp

integer

Medical History
Beschreibung

Medical History

1. HEENT
Beschreibung

1. HEENT

Datentyp

boolean

HEENT: UNK (unknown)
Beschreibung

HEENT

Datentyp

boolean

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

HEENT

Datentyp

text

HEENT
Beschreibung

HEENT

Datentyp

text

2. Respiratory
Beschreibung

2. Respiratory

Datentyp

boolean

Respiratory: UNK
Beschreibung

Respiratory

Datentyp

boolean

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

Respiratory

Datentyp

text

Respiratory
Beschreibung

Respiratory

Datentyp

text

3. Cardiovascular
Beschreibung

3. Cardiovascular

Datentyp

boolean

Cardiovascular: UNK
Beschreibung

Cardiovascular

Datentyp

boolean

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

Cardiovascular

Datentyp

text

Cardiovascular
Beschreibung

Cardiovascular

Datentyp

text

4. Gastrointestinal/Hepatic
Beschreibung

4. Gastrointestinal/Hepatic

Datentyp

boolean

Gastrointestinal/Hepatic: UNK
Beschreibung

Gastrointestinal/Hepatic

Datentyp

boolean

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

Gastrointestinal/Hepatic

Datentyp

text

Gastrointestinal/Hepatic
Beschreibung

Gastrointestinal/Hepatic

Datentyp

text

5. Genitourinary
Beschreibung

5. Genitourinary

Datentyp

boolean

Genitourinary: UNK
Beschreibung

Genitourinary

Datentyp

boolean

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

Genitourinary

Datentyp

text

Genitourinary
Beschreibung

Genitourinary

Datentyp

text

6. Musculoskeletal
Beschreibung

6. Musculoskeletal

Datentyp

boolean

Musculoskeletal: UNK
Beschreibung

Musculoskeletal

Datentyp

boolean

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

Musculoskeletal

Datentyp

text

Musculoskeletal
Beschreibung

Musculoskeletal

Datentyp

text

7. Neurological
Beschreibung

7. Neurological

Datentyp

boolean

Neurological: UNK
Beschreibung

Neurological

Datentyp

boolean

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

Neurological

Datentyp

text

Neurological
Beschreibung

Neurological

Datentyp

text

8. Endocrine-Metabolic
Beschreibung

8. Endocrine-Metabolic

Datentyp

boolean

Endocrine-Metabolic: UNK
Beschreibung

Endocrine-Metabolic

Datentyp

boolean

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

Endocrine-Metabolic

Datentyp

text

Endocrine-Metabolic
Beschreibung

Endocrine-Metabolic

Datentyp

text

9. Hematologic/Lymphatic
Beschreibung

9. Hematologic/Lymphatic

Datentyp

boolean

Hematologic/Lymphatic: UNK
Beschreibung

Hematologic/Lymphatic

Datentyp

boolean

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

Hematologic/Lymphatic

Datentyp

text

Hematologic/Lymphatic
Beschreibung

Hematologic/Lymphatic

Datentyp

text

10. Dermatologic
Beschreibung

10. Dermatologic

Datentyp

boolean

Dermatologic: UNK
Beschreibung

Dermatologic

Datentyp

boolean

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

Dermatologic

Datentyp

text

Dermatologic
Beschreibung

Dermatologic

Datentyp

text

11. Psychiatric
Beschreibung

11. Psychiatric

Datentyp

boolean

Psychiatric: UNK
Beschreibung

Psychiatric

Datentyp

boolean

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

Psychiatric

Datentyp

text

Psychiatric
Beschreibung

Psychiatric

Datentyp

text

12. Allergy
Beschreibung

12. Allergy

Datentyp

boolean

Allergy: UNK
Beschreibung

Allergy: UNK

Datentyp

boolean

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

Allergy

Datentyp

text

Allergy
Beschreibung

Allergy

Datentyp

text

13. Surgical Procedure
Beschreibung

13. Surgical Procedure

Datentyp

boolean

Surgical Procedure: UNK
Beschreibung

Surgical Procedure

Datentyp

boolean

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

Surgical Procedure

Datentyp

text

Surgical Procedure
Beschreibung

Surgical Procedure

Datentyp

text

14. Other (specify)
Beschreibung

14. Other (specify)

Datentyp

boolean

Other (specify)
Beschreibung

Other (specify)

Datentyp

boolean

Other (specify): UNK
Beschreibung

Other (specify)

Datentyp

boolean

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

Other (specify)

Datentyp

text

Other (specify)
Beschreibung

Other (specify)

Datentyp

text

Completed by (initials)
Beschreibung

Completed by (initials)

Datentyp

text

Date completed
Beschreibung

Date completed

Datentyp

date

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Ähnliche Modelle

Medical History Form: UIC Quality Improvement CRF

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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