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ID

16965

Description

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Physical Exam. 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

Keywords

  1. 8/17/16 8/17/16 -
Uploaded on

August 17, 2016

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License

Creative Commons BY-NC 3.0

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    Physical Exam: UIC Quality Improvement CRF

    Physical Exam: UIC Quality Improvement CRF

    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

    text

    Specification of Visit
    Description

    Study Visit

    Data type

    text

    Completion/Early Termination
    Description

    Completion/Early Termination

    Data type

    boolean

    Physical Exam
    Description

    Physical Exam

    General Appearance
    Description

    General Appearance

    Data type

    text

    General Appearance: If abnormal, please describe
    Description

    General Appearance

    Data type

    text

    General Appearance
    Description

    General Appearance: Change from Baseline

    Data type

    text

    HEENT
    Description

    HEENT

    Data type

    text

    HEENT: If abnormal, please describe
    Description

    HEENT

    Data type

    text

    HEENT: Change from Baseline
    Description

    HEENT

    Data type

    text

    Neck
    Description

    Neck

    Data type

    text

    Neck: If abnormal, please describe
    Description

    Neck

    Data type

    text

    Neck: Change from Baseline
    Description

    Neck

    Data type

    text

    Chest and Lungs
    Description

    Chest and Lungs

    Data type

    text

    Chest and Lungs: If abnormal, please describe
    Description

    Chest and Lungs

    Data type

    text

    Chest and Lungs: Change from Baseline
    Description

    Chest and Lungs

    Data type

    text

    Cardiovascular
    Description

    Cardiovascular

    Data type

    text

    Cardiovascular: If abnormal, please describe
    Description

    Cardiovascular

    Data type

    text

    Cardiovascular: Change from Baseline
    Description

    Cardiovascular

    Data type

    text

    Abdomen
    Description

    Abdomen

    Data type

    text

    Abdomen: If abnormal, please describe
    Description

    Abdomen

    Data type

    text

    Abdomen: Change from Baseline
    Description

    Abdomen

    Data type

    text

    Genitourinary
    Description

    Genitourinary

    Data type

    text

    Genitourinary: If abnormal, please describe
    Description

    Genitourinary

    Data type

    text

    Genitourinary: Change from Baseline
    Description

    Genitourinary

    Data type

    text

    Rectal
    Description

    Rectal

    Data type

    text

    Rectal: If abnormal, please describe
    Description

    Rectal

    Data type

    text

    Rectal: Change from Baseline
    Description

    Rectal

    Data type

    text

    Musculoskeletal
    Description

    Musculoskeletal

    Data type

    text

    Musculoskeletal: If abnormal, please describe
    Description

    Musculoskeletal

    Data type

    text

    Musculoskeletal: Change from Baseline
    Description

    Musculoskeletal

    Data type

    text

    Lymph Nodes
    Description

    Lymph Nodes

    Data type

    text

    Lymph Nodes: If abnormal, please describe
    Description

    Lymph Nodes

    Data type

    text

    Lymph Nodes: Change from Baseline
    Description

    Lymph Nodes

    Data type

    text

    Extremities/Skin
    Description

    Extremities/Skin

    Data type

    text

    Extremities/Skin: If abnormal, please describe
    Description

    Extremities/Skin

    Data type

    text

    Extremities/Skin: Change from Baseline
    Description

    Extremities/Skin

    Data type

    text

    Neurological
    Description

    Neurological

    Data type

    text

    Neurological: If abnormal, please describe
    Description

    Neurological

    Data type

    text

    Neurological: Change from Baseline
    Description

    Neurological

    Data type

    text

    Other: Please specify
    Description

    Other

    Data type

    text

    Other
    Description

    Other

    Data type

    text

    Other: If abnormal, please describe
    Description

    Other

    Data type

    text

    Other: Change from Baseline
    Description

    Other

    Data type

    text

    Clinician Signature
    Description

    Clinician Signature

    Data type

    text

    Date Completed
    Description

    Date Completed

    Data type

    date

    Clinician Printed Name
    Description

    Clinician Printed Name

    Data type

    text

    Similar models

    Physical Exam: UIC Quality Improvement CRF

    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
    Item
    Study Visit
    text
    Code List
    Study Visit
    CL Item
    Screening (1)
    CL Item
    Baseline (2)
    CL Item
    Visit (specification) (3)
    Study Visit
    Item
    Specification of Visit
    text
    Completion/Early Termination
    Item
    Completion/Early Termination
    boolean
    Item Group
    Physical Exam
    Item
    General Appearance
    text
    Code List
    General Appearance
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    General Appearance
    Item
    General Appearance: If abnormal, please describe
    text
    Code List
    General Appearance
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    HEENT
    text
    Code List
    HEENT
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    HEENT
    Item
    HEENT: If abnormal, please describe
    text
    Item
    HEENT: Change from Baseline
    text
    Code List
    HEENT: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Neck
    text
    Code List
    Neck
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Neck
    Item
    Neck: If abnormal, please describe
    text
    Item
    Neck: Change from Baseline
    text
    Code List
    Neck: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Chest and Lungs
    text
    Code List
    Chest and Lungs
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Chest and Lungs
    Item
    Chest and Lungs: If abnormal, please describe
    text
    Item
    Chest and Lungs: Change from Baseline
    text
    Code List
    Chest and Lungs: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Cardiovascular
    text
    Code List
    Cardiovascular
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Cardiovascular
    Item
    Cardiovascular: If abnormal, please describe
    text
    Item
    Cardiovascular: Change from Baseline
    text
    Code List
    Cardiovascular: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Abdomen
    text
    Code List
    Abdomen
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Abdomen
    Item
    Abdomen: If abnormal, please describe
    text
    Item
    Abdomen: Change from Baseline
    text
    Code List
    Abdomen: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Genitourinary
    text
    Code List
    Genitourinary
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Genitourinary
    Item
    Genitourinary: If abnormal, please describe
    text
    Item
    Genitourinary: Change from Baseline
    text
    Code List
    Genitourinary: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Rectal
    text
    Code List
    Rectal
    CL Item
    Normal  (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Rectal
    Item
    Rectal: If abnormal, please describe
    text
    Item
    Rectal: Change from Baseline
    text
    Code List
    Rectal: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Musculoskeletal
    text
    Code List
    Musculoskeletal
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Musculoskeletal
    Item
    Musculoskeletal: If abnormal, please describe
    text
    Item
    Musculoskeletal: Change from Baseline
    text
    Code List
    Musculoskeletal: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Lymph Nodes
    text
    Code List
    Lymph Nodes
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Lymph Nodes
    Item
    Lymph Nodes: If abnormal, please describe
    text
    Item
    Lymph Nodes: Change from Baseline
    text
    Code List
    Lymph Nodes: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Extremities/Skin
    text
    Code List
    Extremities/Skin
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Extremities/Skin
    Item
    Extremities/Skin: If abnormal, please describe
    text
    Item
    Extremities/Skin: Change from Baseline
    text
    Code List
    Extremities/Skin: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Item
    Neurological
    text
    Code List
    Neurological
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Neurological
    Item
    Neurological: If abnormal, please describe
    text
    Item
    Neurological: Change from Baseline
    text
    Code List
    Neurological: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Other
    Item
    Other: Please specify
    text
    Item
    Other
    text
    Code List
    Other
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    CL Item
    Not Examined (3)
    Other
    Item
    Other: If abnormal, please describe
    text
    Item
    Other: Change from Baseline
    text
    Code List
    Other: Change from Baseline
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    NA (3)
    Clinician Signature
    Item
    Clinician Signature
    text
    Date Completed
    Item
    Date Completed
    date
    Clinician Printed Name
    Item
    Clinician Printed Name
    text

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