12 Lead ECG
Hematology/Coagulation
Hematology Sample Collection Date
date
Hematology finding; Laboratory test finding
integer
Hematology: clinically significant abnormal laboratory values, please sepcify
If lab abnormalities=Yes
integer
Chemistry, Laboratory findings
Chemistry Sample Collection Date
date
Science of Chemistry; Laboratory test finding
integer
Chemistry: clinically significant abnormal laboratory values, please specify
If lab abnormalities=Yes
integer
Urinanalysis
Urinalysis Sample Collection Date
date
Urinalysis; Laboratory test finding
integer
Urinalysis: clinically significant abnormal laboratory values
If lab abnormalities=Yes
integer
Additional Observations
reference date
date
Visit
text
eCRF
text
Comment
text
Vital Signs
Assessment Date
date
Weight
float
Blood pressure
text
Blood pressure
integer
Heart rate
integer
Respiration Rate
integer
Secondary Endpoint Criteria
cardiovascular event
integer
cardiac consult
integer
cerebrovascular event
integer
neurological consult
integer
Physical Examination
Date of Examination
date
Physical Exam Status
integer
If Clinically significant findings, please specify
integer
If Clinically significant findings, please specify
text