Engelsk

Newly Diagnosed Diabetes Report Form PRoFESS - Prevention Regimen For Effectively Avoiding Second Strokes NCT00153062

1 Formulär  
Newly Diagnosed Diabetes Report Form
Beskrivning

Newly Diagnosed Diabetes Report Form

1. Date of diagnosis (dd mon yy)
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
2. Was the patient on study medication within the 7 days prior to the diagnosis)
Beskrivning

Study Medication Prior To Diagnosis

Datatyp

boolean

If NO, which medication was the patient was not taking (please indicate all that apply):
Beskrivning

if NO

Datatyp

integer

Alias
UMLS CUI [1,1]
C0030705
UMLS CUI [1,2]
C0457432
3. What treatment for diabetes has been described?
Beskrivning

Described Treatment

Datatyp

integer

If medication, specify all that the patient is taking:
Beskrivning

Diabetes Medication

Datatyp

integer

Specify
Beskrivning

Specify

Datatyp

text

Alias
UMLS CUI [1]
C1521902
Assessments
Beskrivning

Assessments

Alias
UMLS CUI-1
C0220825
4. Please indicate which of the following were performed to support the diagnosis: (indicate all that apply)
Beskrivning

Performed to support diagnosis

Datatyp

text

Glucose levels (indicate all that apply)
Beskrivning

Glucose levels

Datatyp

integer

Alias
UMLS CUI [1]
C0202042
Date Of Test (dd mon yy)
Beskrivning

Date Of Test

Datatyp

date

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0011008
Hospitalization
Beskrivning

Hospitalization

Alias
UMLS CUI-1
C0019993
5. Did the lead to hospitalization? If Yes please complete the Hospitalization Report Form.
Beskrivning

Hospitalization

Datatyp

boolean

Fatal Outcome
Beskrivning

Fatal Outcome

6. Was the event fatal (death within 28 days)? If yes please complete Death Report Form.
Beskrivning

Fatal Event

Datatyp

boolean

Invenstigator´s Declaration
Beskrivning

Invenstigator´s Declaration

7. Invenstigator´s Declaration By signing and dating this page, I declare that I have reviewed for accuracy all case report form pages for this patient; the information contained on these pages accurately reflects the medical record including the results of tests and evaluations performed in the dates specified.
Beskrivning

Invenstigator´s Declaration

Datatyp

text

Investigator´s signature
Beskrivning

Investigator´s signature

Datatyp

text

Alias
UMLS CUI [1]
C2346576
Date of Signature
Beskrivning

Date of Signature

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1519316
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Similar models

Newly Diagnosed Diabetes Report Form PRoFESS - Prevention Regimen For Effectively Avoiding Second Strokes NCT00153062

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Newly Diagnosed Diabetes Report Form
Date
Item
1. Date of diagnosis (dd mon yy)
date
C0011008 (UMLS CUI [1])
Study Medication Prior To Diagnosis
Item
2. Was the patient on study medication within the 7 days prior to the diagnosis)
boolean
Item
If NO, which medication was the patient was not taking (please indicate all that apply):
integer
C0030705 (UMLS CUI [1,1])
C0457432 (UMLS CUI [1,2])
if NO
Code List
If NO, which medication was the patient was not taking (please indicate all that apply):
CL Item
Bottle A (1)
CL Item
Bottle B (2)
CL Item
Blister card C (3)
CL Item
Blister card D (4)
Item
3. What treatment for diabetes has been described?
integer
Described Treatment
Code List
3. What treatment for diabetes has been described?
CL Item
None (1)
CL Item
Diet Alone (2)
CL Item
Medication (3)
Item
If medication, specify all that the patient is taking:
integer
Diabetes Medication
Code List
If medication, specify all that the patient is taking:
CL Item
Insulin (1)
CL Item
Thiazolidinediones (e.g.rosiglitazone, pioglitazone) (2)
CL Item
Biguanides (e.g.metformin, hydrochloride) (3)
CL Item
Meglitinides (e.g. repaglinide, nateglinide) (4)
CL Item
Sulfonylurea (e.g.acetohexamide, chlopropamide, gliclazide, glyburide, tolbutamide, glipizide, glimepiride) (5)
CL Item
Alpha-glucosiadase inhibitor (e.g. acarbose, miglitol) (6)
CL Item
Other (7)
Specify
Item
Specify
text
C1521902 (UMLS CUI [1])
Item Group
Assessments
C0220825 (UMLS CUI-1)
Performed to support diagnosis
Item
4. Please indicate which of the following were performed to support the diagnosis: (indicate all that apply)
text
Item
Glucose levels (indicate all that apply)
integer
C0202042 (UMLS CUI [1])
Glucose levels
Code List
Glucose levels (indicate all that apply)
CL Item
Whole Blood (1)
CL Item
Plasma (2)
CL Item
Fasting (3)
CL Item
2 hours after 75gm glucose load (4)
CL Item
HbA1C (5)
Date Of Test
Item
Date Of Test (dd mon yy)
date
C0087111 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item Group
Hospitalization
C0019993 (UMLS CUI-1)
Hospitalization
Item
5. Did the lead to hospitalization? If Yes please complete the Hospitalization Report Form.
boolean
Item Group
Fatal Outcome
Fatal Event
Item
6. Was the event fatal (death within 28 days)? If yes please complete Death Report Form.
boolean
Item Group
Invenstigator´s Declaration
Invenstigator´s Declaration
Item
7. Invenstigator´s Declaration By signing and dating this page, I declare that I have reviewed for accuracy all case report form pages for this patient; the information contained on these pages accurately reflects the medical record including the results of tests and evaluations performed in the dates specified.
text
Investigator´s signature
Item
Investigator´s signature
text
C2346576 (UMLS CUI [1])
Date of Signature
Item
Date of Signature
date
C0011008 (UMLS CUI [1,1])
C1519316 (UMLS CUI [1,2])
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