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

1 Formulários  
Newly Diagnosed Diabetes Report Form
Descrição

Newly Diagnosed Diabetes Report Form

Alias
UMLS CUI-1
C0011849
UMLS CUI-3
C1516308
1. Date of diagnosis (dd mon yy)
Descrição

Date

Tipo de dados

date

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

Study Medication Prior To Diagnosis

Tipo de dados

boolean

Alias
UMLS CUI [1]
C0013227
If NO, which medication was the patient was not taking (please indicate all that apply):
Descrição

if NO

Tipo de dados

integer

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

Described Treatment

Tipo de dados

integer

Alias
UMLS CUI [1,1]
C0011849
UMLS CUI [1,2]
C0087111
If medication, specify all that the patient is taking:
Descrição

Diabetes Medication

Tipo de dados

integer

Alias
UMLS CUI [1]
C0013227
Specify
Descrição

Specify

Tipo de dados

text

Alias
UMLS CUI [1]
C1521902
Assessments
Descrição

Assessments

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

Performed to support diagnosis

Tipo de dados

text

Glucose levels (indicate all that apply)
Descrição

Glucose levels

Tipo de dados

integer

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

Date Of Test

Tipo de dados

date

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

Hospitalization

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

Hospitalization

Tipo de dados

boolean

Fatal Outcome
Descrição

Fatal Outcome

Alias
UMLS CUI-1
C1705586
6. Was the event fatal (death within 28 days)? If yes please complete Death Report Form.
Descrição

Fatal Event

Tipo de dados

boolean

Alias
UMLS CUI [1]
C1705232
Invenstigator´s Declaration
Descrição

Invenstigator´s Declaration

Alias
UMLS CUI-1
C0008961
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.
Descrição

Invenstigator´s Declaration

Tipo de dados

text

Investigator´s signature
Descrição

Investigator´s signature

Tipo de dados

text

Alias
UMLS CUI [1]
C2346576
Date of Signature
Descrição

Date of Signature

Tipo de dados

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 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Newly Diagnosed Diabetes Report Form
C0011849 (UMLS CUI-1)
C1516308 (UMLS CUI-3)
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
C0013227 (UMLS CUI [1])
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
C0011849 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
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
C0013227 (UMLS CUI [1])
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
C1705586 (UMLS CUI-1)
Fatal Event
Item
6. Was the event fatal (death within 28 days)? If yes please complete Death Report Form.
boolean
C1705232 (UMLS CUI [1])
Item Group
Invenstigator´s Declaration
C0008961 (UMLS CUI-1)
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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