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

1 forms  
Newly Diagnosed Diabetes Report Form
Description

Newly Diagnosed Diabetes Report Form

1. Date of diagnosis (dd mon yy)
Description

Date

Data type

date

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

Study Medication Prior To Diagnosis

Data type

boolean

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

if NO

Data type

integer

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

Described Treatment

Data type

integer

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

Diabetes Medication

Data type

integer

Specify
Description

Specify

Data type

text

Alias
UMLS CUI [1]
C1521902
Assessments
Description

Assessments

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

Performed to support diagnosis

Data type

text

Glucose levels (indicate all that apply)
Description

Glucose levels

Data type

integer

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

Date Of Test

Data type

date

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

Hospitalization

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

Hospitalization

Data type

boolean

Fatal Outcome
Description

Fatal Outcome

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

Fatal Event

Data type

boolean

Invenstigator´s Declaration
Description

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.
Description

Invenstigator´s Declaration

Data type

text

Investigator´s signature
Description

Investigator´s signature

Data type

text

Alias
UMLS CUI [1]
C2346576
Date of Signature
Description

Date of Signature

Data type

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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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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