ID

16981

Beschreibung

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

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  1. 17.08.16 17.08.16 -
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17. August 2016

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Medical History II: CRF QMCR University of Alberta

Medical History II: CRF QMCR University of Alberta

General Information
Beschreibung

General Information

Study Name
Beschreibung

Study Name

Datentyp

text

Site Number
Beschreibung

Site Number

Datentyp

integer

Pt_ID
Beschreibung

Pt_ID

Datentyp

integer

Visit Date
Beschreibung

Visit Date

Datentyp

date

Visit Type
Beschreibung

Visit Type

Datentyp

text

Medical History (See Description)
Beschreibung

Medical History (See Description)

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

1. Head, Eye, Ear, Nose, Throat

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

2. Respiratory
Beschreibung

2. Respiratory

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

3. Cardiovascular
Beschreibung

3. Cardiovascular

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

4. Gastrointestinal
Beschreibung

4. Gastrointestinal

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

5. Genitourinary
Beschreibung

5. Genitourinary

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

6. Musculoskeletal
Beschreibung

6. Musculoskeletal

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

7. Neurological
Beschreibung

7. Neurological

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

8. Endocrine-Metabolic
Beschreibung

8. Endocrine-Metabolic

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

9. Blood/Lymphatic
Beschreibung

9. Blood/Lymphatic

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

10. Dermatologic
Beschreibung

10. Dermatologic

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

11. Psychiatric
Beschreibung

11. Psychiatric

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

12. Allergy
Beschreibung

12. Allergy

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

13. Other (specify)
Beschreibung

13. Other (specify)

Datentyp

text

If Other, please specify
Beschreibung

Specification

Datentyp

text

If Yes, Explain
Beschreibung

If Yes, Explain

Datentyp

text

Current/Resolved
Beschreibung

Current/Resolved

Datentyp

text

Ähnliche Modelle

Medical History II: CRF QMCR University of Alberta

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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