ID

18731

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Medical History (General). Case Report Form (CRF)/Source Document templates were created for University of Wisconsin-Madison researchers. These templates are consistent with the FDA's CDASH (Clinical Data Acquisition Standards Harmonization) standards. The CDASH standards identify those elements that should be captured on a Case Report Form (CRF). The forms serve only as templates, and must be edited to meet the study data collection needs as described in the protocol.

Link

https://ictr.wisc.edu/CaseReptTempt

Keywords

Versions (2)
  1. 7/22/16 7/22/16 -
  2. 11/17/16 11/17/16 -
Uploaded on

November 17, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Medical History (General): CRF Wisconsin Madison

English

Medical History (General): CRF Wisconsin Madison

1 forms  
Header
Description

Header

PI Name
Description

PI Name

Data type

text

Alias
UMLS CUI [1,1]
C0027365
UMLS CUI [1,2]
C1521895
Protocol or IRB Number
Description

Protocol or IRB Number

Data type

integer

Alias
UMLS CUI [1]
C2348563
Protocol Short Title
Description

Protocol Short Title

Data type

text

Alias
UMLS CUI [1,1]
C2348563
UMLS CUI [1,2]
C1705824
Subject Initials
Description

Subject Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Subject ID
Description

Subject ID

Data type

integer

Alias
UMLS CUI [1]
C2348585
Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Medical History (General)
Description

Medical History (General)

Insert body system being inquired about
Description

Body System

Data type

text

Alias
UMLS CUI [1]
C0460002
Diagnosed condition
Description

Diagnosed condition

Data type

boolean

Alias
UMLS CUI [1]
C0011900
Diagnosis/Condition/Surgery
Description

Diagnosis/Condition/Surgery

Data type

text

Alias
UMLS CUI [1]
C0011900
UMLS CUI [2]
C0543467
Onset Date or Year
Description

Onset Date or Year

Data type

integer

Alias
UMLS CUI [1]
C0574845
UMLS CUI [2]
C3274945
Current Problem
Description

Current Problem

Data type

boolean

Alias
UMLS CUI [1,1]
C0033213
UMLS CUI [1,2]
C0521116
Other (specify)
Description

Other (specify)

Diagnosed condition
Description

Diagnosed condition

Data type

boolean

Alias
UMLS CUI [1]
C0011900
Diagnosis/Condition/Surgery
Description

Diagnosis/Condition/Surgery

Data type

text

Alias
UMLS CUI [1]
C0011900
UMLS CUI [2]
C0543467
Onset Date Or Year
Description

Onset Date Or Year

Data type

integer

Alias
UMLS CUI [1]
C0574845
UMLS CUI [2]
C3274945
Current Problem
Description

Current Problem

Data type

boolean

Alias
UMLS CUI [1,1]
C0033213
UMLS CUI [1,2]
C0521116
Additional Notes
Description

Additional Notes

Data type

text

Alias
UMLS CUI [1]
C0947611
Medical History Not Obtained
Description

Medical History Not Obtained

Data type

boolean

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C1882120
Medical History Obtained By
Description

Medical History Obtained By

Data type

text

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C1301820
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Similar models

Medical History (General): CRF Wisconsin Madison

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
PI Name
Item
PI Name
text
C0027365 (UMLS CUI [1,1])
C1521895 (UMLS CUI [1,2])
Protocol or IRB Number
Item
Protocol or IRB Number
integer
C2348563 (UMLS CUI [1])
Protocol Short Title
Item
Protocol Short Title
text
C2348563 (UMLS CUI [1,1])
C1705824 (UMLS CUI [1,2])
Subject Initials
Item
Subject Initials
text
C2986440 (UMLS CUI [1])
Subject ID
Item
Subject ID
integer
C2348585 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Item Group
Medical History (General)
Body System
Item
Insert body system being inquired about
text
C0460002 (UMLS CUI [1])
Diagnosed condition
Item
Diagnosed condition
boolean
C0011900 (UMLS CUI [1])
Diagnosis/Condition/Surgery
Item
Diagnosis/Condition/Surgery
text
C0011900 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
Onset Date or Year
Item
Onset Date or Year
integer
C0574845 (UMLS CUI [1])
C3274945 (UMLS CUI [2])
Current Problem
Item
Current Problem
boolean
C0033213 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Item Group
Other (specify)
Diagnosed condition
Item
Diagnosed condition
boolean
C0011900 (UMLS CUI [1])
Diagnosis/Condition/Surgery
Item
Diagnosis/Condition/Surgery
text
C0011900 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
Onset Date Or Year
Item
Onset Date Or Year
integer
C0574845 (UMLS CUI [1])
C3274945 (UMLS CUI [2])
Current Problem
Item
Current Problem
boolean
C0033213 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Additional Notes
Item
Additional Notes
text
C0947611 (UMLS CUI [1])
Medical History Not Obtained
Item
Medical History Not Obtained
boolean
C0262926 (UMLS CUI [1,1])
C1882120 (UMLS CUI [1,2])
Medical History Obtained By
Item
Medical History Obtained By
text
C0262926 (UMLS CUI [1,1])
C1301820 (UMLS CUI [1,2])
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