ID

16878

Beskrivning

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.

Länk

http://research.uic.edu/qip/toolbox/case-report-forms-crf

Nyckelord

Versioner (1)
  1. 2016-08-11 2016-08-11 -
Uppladdad den

11 augusti 2016

DOI

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Licens

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

Engelsk

Medical History Form: UIC Quality Improvement CRF

1 Formulär  
General Information
Beskrivning

General Information

Protocol Title
Beskrivning

Protocol Title

Datatyp

text

Site Number
Beskrivning

Site Number

Datatyp

integer

Subject ID
Beskrivning

Subject ID

Datatyp

integer

Visit Date
Beskrivning

Visit Date

Datatyp

date

Study Visit
Beskrivning

Study Visit

Datatyp

integer

Medical History
Beskrivning

Medical History

1. HEENT
Beskrivning

1. HEENT

Datatyp

boolean

HEENT: UNK (unknown)
Beskrivning

HEENT

Datatyp

boolean

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

HEENT

Datatyp

text

HEENT
Beskrivning

HEENT

Datatyp

text

2. Respiratory
Beskrivning

2. Respiratory

Datatyp

boolean

Respiratory: UNK
Beskrivning

Respiratory

Datatyp

boolean

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

Respiratory

Datatyp

text

Respiratory
Beskrivning

Respiratory

Datatyp

text

3. Cardiovascular
Beskrivning

3. Cardiovascular

Datatyp

boolean

Cardiovascular: UNK
Beskrivning

Cardiovascular

Datatyp

boolean

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

Cardiovascular

Datatyp

text

Cardiovascular
Beskrivning

Cardiovascular

Datatyp

text

4. Gastrointestinal/Hepatic
Beskrivning

4. Gastrointestinal/Hepatic

Datatyp

boolean

Gastrointestinal/Hepatic: UNK
Beskrivning

Gastrointestinal/Hepatic

Datatyp

boolean

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

Gastrointestinal/Hepatic

Datatyp

text

Gastrointestinal/Hepatic
Beskrivning

Gastrointestinal/Hepatic

Datatyp

text

5. Genitourinary
Beskrivning

5. Genitourinary

Datatyp

boolean

Genitourinary: UNK
Beskrivning

Genitourinary

Datatyp

boolean

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

Genitourinary

Datatyp

text

Genitourinary
Beskrivning

Genitourinary

Datatyp

text

6. Musculoskeletal
Beskrivning

6. Musculoskeletal

Datatyp

boolean

Musculoskeletal: UNK
Beskrivning

Musculoskeletal

Datatyp

boolean

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

Musculoskeletal

Datatyp

text

Musculoskeletal
Beskrivning

Musculoskeletal

Datatyp

text

7. Neurological
Beskrivning

7. Neurological

Datatyp

boolean

Neurological: UNK
Beskrivning

Neurological

Datatyp

boolean

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

Neurological

Datatyp

text

Neurological
Beskrivning

Neurological

Datatyp

text

8. Endocrine-Metabolic
Beskrivning

8. Endocrine-Metabolic

Datatyp

boolean

Endocrine-Metabolic: UNK
Beskrivning

Endocrine-Metabolic

Datatyp

boolean

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

Endocrine-Metabolic

Datatyp

text

Endocrine-Metabolic
Beskrivning

Endocrine-Metabolic

Datatyp

text

9. Hematologic/Lymphatic
Beskrivning

9. Hematologic/Lymphatic

Datatyp

boolean

Hematologic/Lymphatic: UNK
Beskrivning

Hematologic/Lymphatic

Datatyp

boolean

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

Hematologic/Lymphatic

Datatyp

text

Hematologic/Lymphatic
Beskrivning

Hematologic/Lymphatic

Datatyp

text

10. Dermatologic
Beskrivning

10. Dermatologic

Datatyp

boolean

Dermatologic: UNK
Beskrivning

Dermatologic

Datatyp

boolean

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

Dermatologic

Datatyp

text

Dermatologic
Beskrivning

Dermatologic

Datatyp

text

11. Psychiatric
Beskrivning

11. Psychiatric

Datatyp

boolean

Psychiatric: UNK
Beskrivning

Psychiatric

Datatyp

boolean

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

Psychiatric

Datatyp

text

Psychiatric
Beskrivning

Psychiatric

Datatyp

text

12. Allergy
Beskrivning

12. Allergy

Datatyp

boolean

Allergy: UNK
Beskrivning

Allergy: UNK

Datatyp

boolean

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

Allergy

Datatyp

text

Allergy
Beskrivning

Allergy

Datatyp

text

13. Surgical Procedure
Beskrivning

13. Surgical Procedure

Datatyp

boolean

Surgical Procedure: UNK
Beskrivning

Surgical Procedure

Datatyp

boolean

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

Surgical Procedure

Datatyp

text

Surgical Procedure
Beskrivning

Surgical Procedure

Datatyp

text

14. Other (specify)
Beskrivning

14. Other (specify)

Datatyp

boolean

Other (specify)
Beskrivning

Other (specify)

Datatyp

boolean

Other (specify): UNK
Beskrivning

Other (specify)

Datatyp

boolean

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

Other (specify)

Datatyp

text

Other (specify)
Beskrivning

Other (specify)

Datatyp

text

Completed by (initials)
Beskrivning

Completed by (initials)

Datatyp

text

Date completed
Beskrivning

Date completed

Datatyp

date

Tillbaka till toppen

Similar models

Medical History Form: UIC Quality Improvement CRF

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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