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22600

Description

Terms of use: You may not use this document or the information contained herein to a regulatory authority in connection with an application for a marketing authorization or any other regulatory submission without the express written consent of Roche Study #: FVF4168g Drug: Ranibizumab Study Title: A Phase III, Double-Masked, Multicenter, Randomized, Sham-Controlled Study Of The Efficacy And Safety Of Ranibizumab Injection In Subjects With Clinically Significant Macular Edema With Center Involvement Secondary To Diabetes Mellitus

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Versions (1)
  1. 6/8/17 6/8/17 -
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Genentech, Inc.

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June 8, 2017

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    TARGETED MEDICAL HISTORY AND BASELINE CONDITIONS (SCREENING) CRFs Roche FVF4168G Macular Edema NCT00473330

    English

    TARGETED MEDICAL HISTORY AND BASELINE CONDITIONS (SCREENING) CRFs Roche FVF4168G Macular Edema NCT00473330

    1 forms  
    Patient administration
    Description

    Patient administration

    Subject Number
    Description

    PT

    Data type

    integer

    Alias
    UMLS CUI [1]
    C2348585
    Subject Initials:
    Description

    PTINIT

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1997894
    UMLS CUI [1,2]
    C2986440
    Report Date:
    Description

    VDT

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C1302584
    TARGETED MEDICAL HISTORY AND BASELINE CONDITIONS (SCREENING)
    Description

    TARGETED MEDICAL HISTORY AND BASELINE CONDITIONS (SCREENING)

    Glaucoma
    Description

    Glaucoma

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0017601
    No Known History
    Description

    Glaucoma medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0017601
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    glaucoma active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0017601
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    glaucoma onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0017601
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    glaucoma onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0017601
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Dry AMD
    Description

    dry AMD

    Data type

    integer

    Alias
    UMLS CUI [1]
    C3888461
    No Known History
    Description

    dry AMD medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C3888461
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    dry AMD active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C3888461
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    dry AMD onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C3888461
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    dry AMD onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C3888461
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Wet AMD
    Description

    wet AMD

    Data type

    text

    Alias
    UMLS CUI [1]
    C3888896
    Condition Currently Active?
    Description

    wet AMD active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C3888896
    UMLS CUI [1,2]
    C2707252
    No Known History
    Description

    wet AMD medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C3888896
    UMLS CUI [1,2]
    C0262926
    Onset Date
    Description

    wet AMD onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C3888896
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    wet AMD onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C3888896
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Hypertension
    Description

    Hypertension

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0020538
    No Known History
    Description

    hypertension medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0020538
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    hypertension active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0020538
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    hypertension onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0020538
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    hypertension onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0020538
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Angina
    Description

    Angina

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0002962
    No Known History
    Description

    angina medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0002962
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    angina active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0002962
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    angina onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0002962
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    angina onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0002962
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Myocardial Infarction
    Description

    Myocardial Infarction

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0027051
    No Known History
    Description

    myocardial infarction medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0027051
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    myocardial infarction active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0027051
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    myocardial infarction onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0027051
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    myocardial infacrction onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0027051
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Congestive Heart Failure
    Description

    Congestive Heart Failure

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0018802
    No Known History
    Description

    congestive heart failure medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0018802
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    congestive heart failure active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0018802
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    congestive heart failure onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0018802
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    congestive heart failure onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0018802
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Transient Ischemic Attack
    Description

    Transient Ischemic Attack

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0007787
    No Known History
    Description

    Transient Ischemic Attack medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0007787
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Transient Ischemic Attack active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0007787
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Transient Ischemic Attack onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0007787
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Transient Ischemic Attack onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0007787
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Cerebral Vascular Accident (Stroke)
    Description

    Cerebral Vascular Accident (Stroke)

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0038454
    No Known History
    Description

    Cerebral Vascular Accident (Stroke) medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0038454
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Cerebral Vascular Accident (Stroke) active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0038454
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Cerebral Vascular Accident (Stroke) onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0038454
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Cerebral Vascular Accident (Stroke) onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0038454
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Diabetes Mellitus
    Description

    Diabetes Mellitus

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0011849
    No Known History
    Description

    Diabetes Mellitus medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0011849
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Diabetes Mellitus active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0011849
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Diabetes Mellitus onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0011849
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Diabetes Mellitus onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0011849
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Prior Non-Ocular Hemorrhage
    Description

    Prior Non-Ocular Hemorrhage

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0019080
    No Known History
    Description

    Prior Non-Ocular Hemorrhage medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0019080
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Prior Non-Ocular Hemorrhage active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0019080
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Prior Non-Ocular Hemorrhage onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0019080
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Prior Non-Ocular Hemorrhage onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0019080
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Deep Venous Thrombosis
    Description

    Deep Venous Thrombosis

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0149871
    No Known History
    Description

    dvt medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0149871
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    dvt active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0149871
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    dvt onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0149871
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    dvt onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0149871
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Endarterectomy
    Description

    Endarterectomy

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0014098
    No Known History
    Description

    Endarterectomy medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0014098
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Endarterectomy active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0014098
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Endarterectomy onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0014098
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Endarterectomy onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0014098
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Renal Failure
    Description

    Renal Failure

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C1533077
    No Known History
    Description

    Renal Failure medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1533077
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Renal Failure active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1533077
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Renal failure onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C1533077
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Renal failure onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1533077
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Coronary Artery Bypass Surgery
    Description

    Coronary Artery Bypass Surgery

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0010055
    No Known History
    Description

    Coronary Artery Bypass Surgery medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0010055
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Coronary Artery Bypass Surgery active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0010055
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Coronary Artery Bypass Surgery onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0010055
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Coronary Artery Bypass Surgery onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0010055
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Coronary Stents
    Description

    Coronary Stents

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0687568
    No Known History
    Description

    Coronary Stents medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0687568
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Coronary Stents active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0687568
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Coronary Stents onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0687568
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Coronary Stents onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0687568
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Coronary Artery Disease (CAD)
    Description

    Coronary Artery Disease (CAD)

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C1956346
    Condition Currently Active?
    Description

    cad active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1956346
    UMLS CUI [1,2]
    C2707252
    No Known History
    Description

    cad medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1956346
    UMLS CUI [1,2]
    C0262926
    Onset Date
    Description

    cad onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C1956346
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    cad onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1956346
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Nose Bleeds
    Description

    Nose Bleeds

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0014591
    Condition Currently Active?
    Description

    Nose Bleeds active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0014591
    UMLS CUI [1,2]
    C2707252
    No Known History
    Description

    Nose Bleeds medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0014591
    UMLS CUI [1,2]
    C0262926
    Onset Date
    Description

    Nose Bleeds onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0014591
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Nose Bleeds onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0014591
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Arrhythmia
    Description

    Arrhythmia

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0003811
    Condition Currently Active?
    Description

    Arrhythmia active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0003811
    UMLS CUI [1,2]
    C2707252
    No Known History
    Description

    Arrhythmia medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0003811
    UMLS CUI [1,2]
    C0262926
    Onset Date
    Description

    Arrhythmia onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0003811
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Arrhythmia onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0003811
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Diverticular Disease
    Description

    Diverticular Disease

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C1510475
    No Known History
    Description

    diverticular disease medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1510475
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Diverticular disease active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1510475
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Diverticular disease onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C1510475
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Diverticular Disease onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1510475
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Proteinuria
    Description

    Proteinuria

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0033687
    No Known History
    Description

    Proteinuria medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0033687
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Proteinuria active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0033687
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Proteinuria onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0033687
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Proteinuria onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0033687
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Rheumatoid Arthritis
    Description

    Rheumatoid Arthritis

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0003873
    No Known History
    Description

    Rheumatoid Arthritis medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0003873
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Rheumatoid Arthritis active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0003873
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Rheumatoid Arthritis onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0003873
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Rheumatoid Arthritis onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0003873
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Dermatitis
    Description

    Dermatitis

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0011603
    No Known History
    Description

    Dermatitis medical history

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0011603
    UMLS CUI [1,2]
    C0262926
    Condition Currently Active?
    Description

    Dermatitis active

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0011603
    UMLS CUI [1,2]
    C2707252
    Onset Date
    Description

    Dermatitis onset date

    Data type

    date

    Measurement units
    • DD/MMM/YY
    Alias
    UMLS CUI [1,1]
    C0011603
    UMLS CUI [1,2]
    C0574845
    DD/MMM/YY
    Date Unknown
    Description

    Dermatitis onset date unknown

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0011603
    UMLS CUI [1,2]
    C0574845
    UMLS CUI [1,3]
    C0439673
    Back to the top of the page

    Similar models

    TARGETED MEDICAL HISTORY AND BASELINE CONDITIONS (SCREENING) CRFs Roche FVF4168G Macular Edema NCT00473330

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Patient administration
    PT
    Item
    Subject Number
    integer
    C2348585 (UMLS CUI [1])
    PTINIT
    Item
    Subject Initials:
    text
    C1997894 (UMLS CUI [1,1])
    C2986440 (UMLS CUI [1,2])
    VDT
    Item
    Report Date:
    date
    C1302584 (UMLS CUI [1,1])
    Item Group
    TARGETED MEDICAL HISTORY AND BASELINE CONDITIONS (SCREENING)
    Item
    Glaucoma
    integer
    C0017601 (UMLS CUI [1])
    PROCEDURE_TYPE [PRCTYP]
    Code List
    Glaucoma
    CL Item
    Applanation tonometry (1)
    CL Item
    Non-contact tonometry (2)
    CL Item
    Tonopen (3)
    CL Item
    Pneumotonometry (4)
    Glaucoma medical history
    Item
    No Known History
    boolean
    C0017601 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    glaucoma active
    Item
    Condition Currently Active?
    boolean
    C0017601 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    glaucoma onset date
    Item
    Onset Date
    date
    C0017601 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    glaucoma onset date unknown
    Item
    Date Unknown
    boolean
    C0017601 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Item
    Dry AMD
    integer
    C3888461 (UMLS CUI [1])
    PROCEDURE_TYPE [PRCTYP]
    Code List
    Dry AMD
    CL Item
    Applanation tonometry (1)
    CL Item
    Non-contact tonometry (2)
    CL Item
    Tonopen (3)
    CL Item
    Pneumotonometry (4)
    dry AMD medical history
    Item
    No Known History
    boolean
    C3888461 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    dry AMD active
    Item
    Condition Currently Active?
    boolean
    C3888461 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    dry AMD onset date
    Item
    Onset Date
    date
    C3888461 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    dry AMD onset date unknown
    Item
    Date Unknown
    boolean
    C3888461 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    wet AMD
    Item
    Wet AMD
    text
    C3888896 (UMLS CUI [1])
    wet AMD active
    Item
    Condition Currently Active?
    boolean
    C3888896 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    wet AMD medical history
    Item
    No Known History
    boolean
    C3888896 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    wet AMD onset date
    Item
    Onset Date
    date
    C3888896 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    wet AMD onset date unknown
    Item
    Date Unknown
    boolean
    C3888896 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Hypertension
    Item
    Hypertension
    boolean
    C0020538 (UMLS CUI [1])
    hypertension medical history
    Item
    No Known History
    boolean
    C0020538 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    hypertension active
    Item
    Condition Currently Active?
    boolean
    C0020538 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    hypertension onset date
    Item
    Onset Date
    date
    C0020538 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    hypertension onset date unknown
    Item
    Date Unknown
    boolean
    C0020538 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Angina
    Item
    Angina
    boolean
    C0002962 (UMLS CUI [1])
    angina medical history
    Item
    No Known History
    boolean
    C0002962 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    angina active
    Item
    Condition Currently Active?
    boolean
    C0002962 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    angina onset date
    Item
    Onset Date
    date
    C0002962 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    angina onset date unknown
    Item
    Date Unknown
    boolean
    C0002962 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Myocardial Infarction
    Item
    Myocardial Infarction
    boolean
    C0027051 (UMLS CUI [1])
    myocardial infarction medical history
    Item
    No Known History
    boolean
    C0027051 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    myocardial infarction active
    Item
    Condition Currently Active?
    boolean
    C0027051 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    myocardial infarction onset date
    Item
    Onset Date
    date
    C0027051 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    myocardial infacrction onset date unknown
    Item
    Date Unknown
    boolean
    C0027051 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Congestive Heart Failure
    Item
    Congestive Heart Failure
    boolean
    C0018802 (UMLS CUI [1])
    congestive heart failure medical history
    Item
    No Known History
    boolean
    C0018802 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    congestive heart failure active
    Item
    Condition Currently Active?
    boolean
    C0018802 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    congestive heart failure onset date
    Item
    Onset Date
    date
    C0018802 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    congestive heart failure onset date unknown
    Item
    Date Unknown
    boolean
    C0018802 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Transient Ischemic Attack
    Item
    Transient Ischemic Attack
    boolean
    C0007787 (UMLS CUI [1])
    Transient Ischemic Attack medical history
    Item
    No Known History
    boolean
    C0007787 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Transient Ischemic Attack active
    Item
    Condition Currently Active?
    boolean
    C0007787 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Transient Ischemic Attack onset date
    Item
    Onset Date
    date
    C0007787 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Transient Ischemic Attack onset date unknown
    Item
    Date Unknown
    boolean
    C0007787 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Cerebral Vascular Accident (Stroke)
    Item
    Cerebral Vascular Accident (Stroke)
    boolean
    C0038454 (UMLS CUI [1])
    Cerebral Vascular Accident (Stroke) medical history
    Item
    No Known History
    boolean
    C0038454 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Cerebral Vascular Accident (Stroke) active
    Item
    Condition Currently Active?
    boolean
    C0038454 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Cerebral Vascular Accident (Stroke) onset date
    Item
    Onset Date
    date
    C0038454 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Cerebral Vascular Accident (Stroke) onset date unknown
    Item
    Date Unknown
    boolean
    C0038454 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Diabetes Mellitus
    Item
    Diabetes Mellitus
    boolean
    C0011849 (UMLS CUI [1])
    Diabetes Mellitus medical history
    Item
    No Known History
    boolean
    C0011849 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Diabetes Mellitus active
    Item
    Condition Currently Active?
    boolean
    C0011849 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Diabetes Mellitus onset date
    Item
    Onset Date
    date
    C0011849 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Diabetes Mellitus onset date unknown
    Item
    Date Unknown
    boolean
    C0011849 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Prior Non-Ocular Hemorrhage
    Item
    Prior Non-Ocular Hemorrhage
    boolean
    C0019080 (UMLS CUI [1])
    Prior Non-Ocular Hemorrhage medical history
    Item
    No Known History
    boolean
    C0019080 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Prior Non-Ocular Hemorrhage active
    Item
    Condition Currently Active?
    boolean
    C0019080 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Prior Non-Ocular Hemorrhage onset date
    Item
    Onset Date
    date
    C0019080 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Prior Non-Ocular Hemorrhage onset date unknown
    Item
    Date Unknown
    boolean
    C0019080 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Deep Venous Thrombosis
    Item
    Deep Venous Thrombosis
    boolean
    C0149871 (UMLS CUI [1])
    dvt medical history
    Item
    No Known History
    boolean
    C0149871 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    dvt active
    Item
    Condition Currently Active?
    boolean
    C0149871 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    dvt onset date
    Item
    Onset Date
    date
    C0149871 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    dvt onset date unknown
    Item
    Date Unknown
    boolean
    C0149871 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Endarterectomy
    Item
    Endarterectomy
    boolean
    C0014098 (UMLS CUI [1])
    Endarterectomy medical history
    Item
    No Known History
    boolean
    C0014098 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Endarterectomy active
    Item
    Condition Currently Active?
    boolean
    C0014098 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Endarterectomy onset date
    Item
    Onset Date
    date
    C0014098 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Endarterectomy onset date unknown
    Item
    Date Unknown
    boolean
    C0014098 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Renal Failure
    Item
    Renal Failure
    boolean
    C1533077 (UMLS CUI [1])
    Renal Failure medical history
    Item
    No Known History
    boolean
    C1533077 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Renal Failure active
    Item
    Condition Currently Active?
    boolean
    C1533077 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Renal failure onset date
    Item
    Onset Date
    date
    C1533077 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Renal failure onset date unknown
    Item
    Date Unknown
    boolean
    C1533077 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Coronary Artery Bypass Surgery
    Item
    Coronary Artery Bypass Surgery
    boolean
    C0010055 (UMLS CUI [1])
    Coronary Artery Bypass Surgery medical history
    Item
    No Known History
    boolean
    C0010055 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Coronary Artery Bypass Surgery active
    Item
    Condition Currently Active?
    boolean
    C0010055 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Coronary Artery Bypass Surgery onset date
    Item
    Onset Date
    date
    C0010055 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Coronary Artery Bypass Surgery onset date unknown
    Item
    Date Unknown
    boolean
    C0010055 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Coronary Stents
    Item
    Coronary Stents
    boolean
    C0687568 (UMLS CUI [1])
    Coronary Stents medical history
    Item
    No Known History
    boolean
    C0687568 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Coronary Stents active
    Item
    Condition Currently Active?
    boolean
    C0687568 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Coronary Stents onset date
    Item
    Onset Date
    date
    C0687568 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Coronary Stents onset date unknown
    Item
    Date Unknown
    boolean
    C0687568 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Coronary Artery Disease (CAD)
    Item
    Coronary Artery Disease (CAD)
    boolean
    C1956346 (UMLS CUI [1])
    cad active
    Item
    Condition Currently Active?
    boolean
    C1956346 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    cad medical history
    Item
    No Known History
    boolean
    C1956346 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    cad onset date
    Item
    Onset Date
    date
    C1956346 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    cad onset date unknown
    Item
    Date Unknown
    boolean
    C1956346 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Nose Bleeds
    Item
    Nose Bleeds
    boolean
    C0014591 (UMLS CUI [1])
    Nose Bleeds active
    Item
    Condition Currently Active?
    boolean
    C0014591 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Nose Bleeds medical history
    Item
    No Known History
    boolean
    C0014591 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Nose Bleeds onset date
    Item
    Onset Date
    date
    C0014591 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Nose Bleeds onset date unknown
    Item
    Date Unknown
    boolean
    C0014591 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Arrhythmia
    Item
    Arrhythmia
    boolean
    C0003811 (UMLS CUI [1])
    Arrhythmia active
    Item
    Condition Currently Active?
    boolean
    C0003811 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Arrhythmia medical history
    Item
    No Known History
    boolean
    C0003811 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Arrhythmia onset date
    Item
    Onset Date
    date
    C0003811 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Arrhythmia onset date unknown
    Item
    Date Unknown
    boolean
    C0003811 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Diverticular Disease
    Item
    Diverticular Disease
    boolean
    C1510475 (UMLS CUI [1])
    diverticular disease medical history
    Item
    No Known History
    boolean
    C1510475 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Diverticular disease active
    Item
    Condition Currently Active?
    boolean
    C1510475 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Diverticular disease onset date
    Item
    Onset Date
    date
    C1510475 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Diverticular Disease onset date unknown
    Item
    Date Unknown
    boolean
    C1510475 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Proteinuria
    Item
    Proteinuria
    boolean
    C0033687 (UMLS CUI [1])
    Proteinuria medical history
    Item
    No Known History
    boolean
    C0033687 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Proteinuria active
    Item
    Condition Currently Active?
    boolean
    C0033687 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Proteinuria onset date
    Item
    Onset Date
    date
    C0033687 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Proteinuria onset date unknown
    Item
    Date Unknown
    boolean
    C0033687 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Rheumatoid Arthritis
    Item
    Rheumatoid Arthritis
    boolean
    C0003873 (UMLS CUI [1])
    Rheumatoid Arthritis medical history
    Item
    No Known History
    boolean
    C0003873 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Rheumatoid Arthritis active
    Item
    Condition Currently Active?
    boolean
    C0003873 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Rheumatoid Arthritis onset date
    Item
    Onset Date
    date
    C0003873 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Rheumatoid Arthritis onset date unknown
    Item
    Date Unknown
    boolean
    C0003873 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
    Dermatitis
    Item
    Dermatitis
    boolean
    C0011603 (UMLS CUI [1])
    Dermatitis medical history
    Item
    No Known History
    boolean
    C0011603 (UMLS CUI [1,1])
    C0262926 (UMLS CUI [1,2])
    Dermatitis active
    Item
    Condition Currently Active?
    boolean
    C0011603 (UMLS CUI [1,1])
    C2707252 (UMLS CUI [1,2])
    Dermatitis onset date
    Item
    Onset Date
    date
    C0011603 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    Dermatitis onset date unknown
    Item
    Date Unknown
    boolean
    C0011603 (UMLS CUI [1,1])
    C0574845 (UMLS CUI [1,2])
    C0439673 (UMLS CUI [1,3])
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