ID

16878

Beschrijving

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

Trefwoorden

Versies (1)
  1. 11-08-16 11-08-16 -
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11 augustus 2016

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Creative Commons BY-NC 3.0
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Medical History Form: UIC Quality Improvement CRF

Engels

Medical History Form: UIC Quality Improvement CRF

1 Formulieren  
General Information
Beschrijving

General Information

Protocol Title
Beschrijving

Protocol Title

Datatype

text

Site Number
Beschrijving

Site Number

Datatype

integer

Subject ID
Beschrijving

Subject ID

Datatype

integer

Visit Date
Beschrijving

Visit Date

Datatype

date

Study Visit
Beschrijving

Study Visit

Datatype

integer

Medical History
Beschrijving

Medical History

1. HEENT
Beschrijving

1. HEENT

Datatype

boolean

HEENT: UNK (unknown)
Beschrijving

HEENT

Datatype

boolean

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

HEENT

Datatype

text

HEENT
Beschrijving

HEENT

Datatype

text

2. Respiratory
Beschrijving

2. Respiratory

Datatype

boolean

Respiratory: UNK
Beschrijving

Respiratory

Datatype

boolean

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

Respiratory

Datatype

text

Respiratory
Beschrijving

Respiratory

Datatype

text

3. Cardiovascular
Beschrijving

3. Cardiovascular

Datatype

boolean

Cardiovascular: UNK
Beschrijving

Cardiovascular

Datatype

boolean

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

Cardiovascular

Datatype

text

Cardiovascular
Beschrijving

Cardiovascular

Datatype

text

4. Gastrointestinal/Hepatic
Beschrijving

4. Gastrointestinal/Hepatic

Datatype

boolean

Gastrointestinal/Hepatic: UNK
Beschrijving

Gastrointestinal/Hepatic

Datatype

boolean

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

Gastrointestinal/Hepatic

Datatype

text

Gastrointestinal/Hepatic
Beschrijving

Gastrointestinal/Hepatic

Datatype

text

5. Genitourinary
Beschrijving

5. Genitourinary

Datatype

boolean

Genitourinary: UNK
Beschrijving

Genitourinary

Datatype

boolean

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

Genitourinary

Datatype

text

Genitourinary
Beschrijving

Genitourinary

Datatype

text

6. Musculoskeletal
Beschrijving

6. Musculoskeletal

Datatype

boolean

Musculoskeletal: UNK
Beschrijving

Musculoskeletal

Datatype

boolean

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

Musculoskeletal

Datatype

text

Musculoskeletal
Beschrijving

Musculoskeletal

Datatype

text

7. Neurological
Beschrijving

7. Neurological

Datatype

boolean

Neurological: UNK
Beschrijving

Neurological

Datatype

boolean

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

Neurological

Datatype

text

Neurological
Beschrijving

Neurological

Datatype

text

8. Endocrine-Metabolic
Beschrijving

8. Endocrine-Metabolic

Datatype

boolean

Endocrine-Metabolic: UNK
Beschrijving

Endocrine-Metabolic

Datatype

boolean

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

Endocrine-Metabolic

Datatype

text

Endocrine-Metabolic
Beschrijving

Endocrine-Metabolic

Datatype

text

9. Hematologic/Lymphatic
Beschrijving

9. Hematologic/Lymphatic

Datatype

boolean

Hematologic/Lymphatic: UNK
Beschrijving

Hematologic/Lymphatic

Datatype

boolean

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

Hematologic/Lymphatic

Datatype

text

Hematologic/Lymphatic
Beschrijving

Hematologic/Lymphatic

Datatype

text

10. Dermatologic
Beschrijving

10. Dermatologic

Datatype

boolean

Dermatologic: UNK
Beschrijving

Dermatologic

Datatype

boolean

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

Dermatologic

Datatype

text

Dermatologic
Beschrijving

Dermatologic

Datatype

text

11. Psychiatric
Beschrijving

11. Psychiatric

Datatype

boolean

Psychiatric: UNK
Beschrijving

Psychiatric

Datatype

boolean

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

Psychiatric

Datatype

text

Psychiatric
Beschrijving

Psychiatric

Datatype

text

12. Allergy
Beschrijving

12. Allergy

Datatype

boolean

Allergy: UNK
Beschrijving

Allergy: UNK

Datatype

boolean

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

Allergy

Datatype

text

Allergy
Beschrijving

Allergy

Datatype

text

13. Surgical Procedure
Beschrijving

13. Surgical Procedure

Datatype

boolean

Surgical Procedure: UNK
Beschrijving

Surgical Procedure

Datatype

boolean

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

Surgical Procedure

Datatype

text

Surgical Procedure
Beschrijving

Surgical Procedure

Datatype

text

14. Other (specify)
Beschrijving

14. Other (specify)

Datatype

boolean

Other (specify)
Beschrijving

Other (specify)

Datatype

boolean

Other (specify): UNK
Beschrijving

Other (specify)

Datatype

boolean

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

Other (specify)

Datatype

text

Other (specify)
Beschrijving

Other (specify)

Datatype

text

Completed by (initials)
Beschrijving

Completed by (initials)

Datatype

text

Date completed
Beschrijving

Date completed

Datatype

date

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Similar models

Medical History Form: UIC Quality Improvement CRF

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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