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ID

16981

Description

ODM derived from: http://www.qmcr.ualberta.ca/en/ToolsandTemplates/CaseReportFormCRFTemplates.aspx. Template Name: Medical History II. University of Alberta, Quality Management in Clinical Research. Copyright: 2002-2016 University of Alberta.

Link

http://www.qmcr.ualberta.ca/en/ToolsandTemplates/CaseReportFormCRFTemplates.aspx

Keywords

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

August 17, 2016

DOI

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License

Creative Commons BY-NC 3.0

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    Medical History II: CRF QMCR University of Alberta

    Medical History II: CRF QMCR University of Alberta

    General Information
    Description

    General Information

    Study Name
    Description

    Study Name

    Data type

    text

    Site Number
    Description

    Site Number

    Data type

    integer

    Pt_ID
    Description

    Pt_ID

    Data type

    integer

    Visit Date
    Description

    Visit Date

    Data type

    date

    Visit Type
    Description

    Visit Type

    Data type

    text

    Medical History (See Description)
    Description

    Medical History (See Description)

    1. Head, Eye, Ear, Nose, Throat
    Description

    1. Head, Eye, Ear, Nose, Throat

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    2. Respiratory
    Description

    2. Respiratory

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    3. Cardiovascular
    Description

    3. Cardiovascular

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    4. Gastrointestinal
    Description

    4. Gastrointestinal

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    5. Genitourinary
    Description

    5. Genitourinary

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    6. Musculoskeletal
    Description

    6. Musculoskeletal

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    7. Neurological
    Description

    7. Neurological

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    8. Endocrine-Metabolic
    Description

    8. Endocrine-Metabolic

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    9. Blood/Lymphatic
    Description

    9. Blood/Lymphatic

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    10. Dermatologic
    Description

    10. Dermatologic

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    11. Psychiatric
    Description

    11. Psychiatric

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    12. Allergy
    Description

    12. Allergy

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    13. Other (specify)
    Description

    13. Other (specify)

    Data type

    text

    If Other, please specify
    Description

    Specification

    Data type

    text

    If Yes, Explain
    Description

    If Yes, Explain

    Data type

    text

    Current/Resolved
    Description

    Current/Resolved

    Data type

    text

    Similar models

    Medical History II: CRF QMCR University of Alberta

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    General Information
    Study Name
    Item
    Study Name
    text
    Site Number
    Item
    Site Number
    integer
    Pt_ID
    Item
    Pt_ID
    integer
    Visit Date
    Item
    Visit Date
    date
    Item
    Visit Type
    text
    Code List
    Visit Type
    CL Item
    Screening (1)
    CL Item
    Baseline (2)
    Item Group
    Medical History (See Description)
    Item
    1. Head, Eye, Ear, Nose, Throat
    text
    Code List
    1. Head, Eye, Ear, Nose, Throat
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    2. Respiratory
    text
    Code List
    2. Respiratory
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    3. Cardiovascular
    text
    Code List
    3. Cardiovascular
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    4. Gastrointestinal
    text
    Code List
    4. Gastrointestinal
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    5. Genitourinary
    text
    Code List
    5. Genitourinary
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    6. Musculoskeletal
    text
    Code List
    6. Musculoskeletal
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    7. Neurological
    text
    Code List
    7. Neurological
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    8. Endocrine-Metabolic
    text
    Code List
    8. Endocrine-Metabolic
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    9. Blood/Lymphatic
    text
    Code List
    9. Blood/Lymphatic
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    10. Dermatologic
    text
    Code List
    10. Dermatologic
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    11. Psychiatric
    text
    Code List
    11. Psychiatric
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    12. Allergy
    text
    Code List
    12. Allergy
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)
    Item
    13. Other (specify)
    text
    Code List
    13. Other (specify)
    CL Item
    Yes (1)
    CL Item
    No (2)
    CL Item
    Unknown (3)
    Specification
    Item
    If Other, please specify
    text
    If Yes, Explain
    Item
    If Yes, Explain
    text
    Item
    Current/Resolved
    text
    Code List
    Current/Resolved
    CL Item
    Current (1)
    CL Item
    Resolved (2)

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