Last Intake of Drug A, B and C
Item
1. Last intake of trial drug A, B and C (dd mon yy)
date
C0011008 (UMLS CUI [1,1])
C1512806 (UMLS CUI [1,2])
Last Intake of Drug D
Item
2. Last intake of trial drug D (dd mon yy)
date
C0011008 (UMLS CUI [1,1])
C1512806 (UMLS CUI [1,2])
Permanently stopped taking medication
Item
3. Did the patient permanently stopped taking any of the trial medication prematurely
boolean
C0850893 (UMLS CUI [1])
If Yes
Item
4. If yes please check which arm of the trial medication (ABC, D or all ABCD) and the reasons why for each treatment arm discontinued. (indicate one reason):
text
C3146298 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0457454 (UMLS CUI [1,3])
Item
A. Outcome Event (must be recorded on outcome event page)
integer
C0441471 (UMLS CUI [1,1])
C1547647 (UMLS CUI [1,2])
C0441471 (UMLS CUI [1,3])
Code List
A. Outcome Event (must be recorded on outcome event page)
Item
B. Adverse Event (Specify Adverse Event below)
integer
C0877248 (UMLS CUI [1])
Code List
B. Adverse Event (Specify Adverse Event below)
Adverse Event
Item
Specify Adverse Event
text
C2348235 (UMLS CUI [1,1])
C0877248 (UMLS CUI [1,2])
Item
C. Non compliant with protocol (explain below)
integer
C1321605 (UMLS CUI [1,1])
C2348563 (UMLS CUI [1,2])
Code List
C. Non compliant with protocol (explain below)
Item
D. Lost to follow-up (explain below)
integer
C1522577 (UMLS CUI [1])
Code List
D. Lost to follow-up (explain below)
Item
E. Consent withdrawn (not due to adverse event, explain below)
integer
C1707492 (UMLS CUI [1])
Code List
E. Consent withdrawn (not due to adverse event, explain below)
Item
F. Other (explain below)
integer
C0205394 (UMLS CUI [1])
Code List
F. Other (explain below)
Explain
Item
Explain
text
C1521902 (UMLS CUI [1])