General Information
Study Name
text
Site Number
integer
Pt_ID
Visit Date
date
Visit Type
Medical History (See Description)
1. Head, Eye, Ear, Nose, Throat
If Yes, Explain
Current/Resolved
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Genitourinary
6. Musculoskeletal
7. Neurological
8. Endocrine-Metabolic
9. Blood/Lymphatic
10. Dermatologic
11. Psychiatric
12. Allergy
13. Other (specify)
Specification