ID

25104

Beschreibung

Visit 6 Booster Dose General Symptoms form Study ID: 208127/125 Clinical Study ID: 208127/125 (Ext-HAB-038 Month 90) Study Title: A double-blind, randomized study to evaluate the immunogenicity and reactogenicity of two different lots of GlaxoSmithKline Biologicals' combined hepatitis A / hepatitis B vaccine in healthy children between 6 and 15 years of age. Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: N/A Sponsor:GlaxoSmithKline Collaborators: N/A Phase: Phase 3 Study Recruitment Status: Completed Generic Name: Hepatitis A (Inactivated), Hepatitis B (Recombinant) Vaccine Trade Name: Twinrix Study Indication: Hepatitis A; Hepatitis B

Stichworte

Versionen (1)
  1. 25.08.17 25.08.17 -
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GlaxoSmithKline

Hochgeladen am

25. August 2017

DOI

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Visit 6 Booster Dose General Symptoms Biologicals HepA/HepB vaccine 208127/125

Englisch

Visit 6 Booster Dose General Symptoms Biologicals HepA/HepB vaccine 208127/125

1 Formulare  
Header
Beschreibung

Header

Alias
UMLS CUI-1
C1320722
Protocol
Beschreibung

Protocol

Datentyp

text

Alias
UMLS CUI [1]
C1507394
Activity
Beschreibung

Activity

Datentyp

text

Alias
UMLS CUI [1]
C1512346
Subject number
Beschreibung

Subject number

Datentyp

text

Alias
UMLS CUI [1]
C2348585
SOLICITED ADVERSE EXPERIENCES - GENERAL SYMPTOMS
Beschreibung

SOLICITED ADVERSE EXPERIENCES - GENERAL SYMPTOMS

Alias
UMLS CUI-1
C0877248
UMLS CUI-2
C0159028
IV. Has the subject experienced any general solicited signs or symptoms since vaccine administration ?
Beschreibung

if No: Please, go to paragraph V. if Yes: Please tick a No/Yes box for each symptom. If any experience was observed, please fill in the complete line.

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0159028
UMLS CUI [1,2]
C2368628
Temperature
Beschreibung

Temperature

Alias
UMLS CUI-1
C0005903
GENERAL SYMPTOMS
Beschreibung

General Symptoms

Datentyp

boolean

Alias
UMLS CUI [1]
C0159028
Axillary ≥ 37,5°C
Beschreibung

Axillary temperature

Datentyp

boolean

Alias
UMLS CUI [1]
C1531924
Oral ≥ 37,5°C
Beschreibung

Oral temperature

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C0442027
Rectal ≥ 38°C
Beschreibung

Rectal temperature

Datentyp

boolean

Alias
UMLS CUI [1]
C0489749
Temperature Day 0
Beschreibung

Temperature Day 0

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C2826301
°C
Not taken
Beschreibung

Temperature Day 0 not taken

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2826301
UMLS CUI [1,2]
C0437722
Temperature Day 1
Beschreibung

Temperature Day 1

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C1442449
°C
Not taken
Beschreibung

Temperature Day 1 not taken

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1442449
UMLS CUI [1,2]
C0437722
Temperature Day 2
Beschreibung

Temperature Day 2

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C3842676
°C
Not taken
Beschreibung

Temperature Day 2 not taken

Datentyp

boolean

Alias
UMLS CUI [1,1]
C3842676
UMLS CUI [1,2]
C0437722
Temperature Day 3
Beschreibung

Temperature Day 3

Datentyp

float

Maßeinheiten
  • °C
Alias
UMLS CUI [1,1]
C0005903
UMLS CUI [1,2]
C3842675
°C
Not taken
Beschreibung

Temperature Day 3 not taken

Datentyp

boolean

Alias
UMLS CUI [1,1]
C3842675
UMLS CUI [1,2]
C0437722
Corrective therapy ?
Beschreibung

Corrective therapy : if Yes, record in the Medication Section

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Relation
Beschreibung

Relation

Datentyp

text

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0085978
UMLS CUI [1,3]
C1518404
Outcome
Beschreibung

0utcome : if still ongoing at the end of day 3, please record experience in the Adverse Experience Section

Datentyp

integer

Alias
UMLS CUI [1]
C1705586
Headache
Beschreibung

Headache

Alias
UMLS CUI-1
C0018681
GENERAL SYMPTOMS
Beschreibung

General symptoms

Datentyp

boolean

Alias
UMLS CUI [1]
C0159028
Intensity Day 0
Beschreibung

Intensity Day 0

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826301
Intensity Day 1
Beschreibung

Intensity Day 1

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C1442449
Intensity Day 2
Beschreibung

Intensity Day 2

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842676
Intensity Day 3
Beschreibung

Intensity Day 3

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842675
Corrective therapy ?
Beschreibung

Corrective therapy : if Yes, record in the Medication Section

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Relation
Beschreibung

Relation

Datentyp

text

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0085978
UMLS CUI [1,3]
C1518404
Outcome
Beschreibung

0utcome : if still ongoing at the end of day 3, please record experience in the Adverse Experience Section

Datentyp

integer

Alias
UMLS CUI [1]
C1705586
Malaise
Beschreibung

Malaise

Alias
UMLS CUI-1
C0231218
GENERAL SYMPTOMS
Beschreibung

General symptoms

Datentyp

boolean

Alias
UMLS CUI [1]
C0159028
Intensity Day 0
Beschreibung

Intensity Day 0

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826301
Intensity Day 1
Beschreibung

Intensity Day 1

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C1442449
Intensity Day 2
Beschreibung

Intensity Day 2

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842676
Intensity Day 3
Beschreibung

Intensity Day 3

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842675
Corrective therapy ?
Beschreibung

Corrective therapy : if Yes, record in the Medication Section

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Relation
Beschreibung

Relation

Datentyp

text

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0085978
UMLS CUI [1,3]
C1518404
Outcome
Beschreibung

0utcome : if still ongoing at the end of day 3, please record experience in the Adverse Experience Section

Datentyp

integer

Alias
UMLS CUI [1]
C1705586
Fatigue
Beschreibung

Fatigue

Alias
UMLS CUI-1
C0015672
GENERAL SYMPTOMS
Beschreibung

General symptoms

Datentyp

boolean

Alias
UMLS CUI [1]
C0159028
Intensity Day 0
Beschreibung

Intensity Day 0

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826301
Intensity Day 1
Beschreibung

Intensity Day 1

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C1442449
Intensity Day 2
Beschreibung

Intensity Day 2

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842676
Intensity Day 3
Beschreibung

Intensity Day 3

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842675
Corrective therapy ?
Beschreibung

Corrective therapy : if Yes, record in the Medication Section

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Relation
Beschreibung

Relation

Datentyp

text

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0085978
UMLS CUI [1,3]
C1518404
Outcome
Beschreibung

0utcome : if still ongoing at the end of day 3, please record experience in the Adverse Experience Section

Datentyp

integer

Alias
UMLS CUI [1]
C1705586
Nausea
Beschreibung

Nausea

Alias
UMLS CUI-1
C0027497
GENERAL SYMPTOMS
Beschreibung

General symptoms

Datentyp

boolean

Alias
UMLS CUI [1]
C0159028
Intensity Day 0
Beschreibung

Intensity Day 0

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826301
Intensity Day 1
Beschreibung

Intensity Day 1

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C1442449
Intensity Day 2
Beschreibung

Intensity Day 2

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842676
Intensity Day 3
Beschreibung

Intensity Day 3

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842675
Corrective therapy ?
Beschreibung

Corrective therapy : if Yes, record in the Medication Section

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Relation
Beschreibung

Relation

Datentyp

text

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0085978
UMLS CUI [1,3]
C1518404
Outcome
Beschreibung

0utcome : if still ongoing at the end of day 3, please record experience in the Adverse Experience Section

Datentyp

integer

Alias
UMLS CUI [1]
C1705586
Vomiting
Beschreibung

Vomiting

Alias
UMLS CUI-1
C0042963
GENERAL SYMPTOMS
Beschreibung

General symptoms

Datentyp

boolean

Alias
UMLS CUI [1]
C0159028
Intensity Day 0
Beschreibung

Intensity Day 0

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C2826301
Intensity Day 1
Beschreibung

Intensity Day 1

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C1442449
Intensity Day 2
Beschreibung

Intensity Day 2

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842676
Intensity Day 3
Beschreibung

Intensity Day 3

Datentyp

integer

Alias
UMLS CUI [1,1]
C0518690
UMLS CUI [1,2]
C3842675
Corrective therapy ?
Beschreibung

Corrective therapy : if Yes, record in the Medication Section

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Relation
Beschreibung

Relation

Datentyp

text

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0085978
UMLS CUI [1,3]
C1518404
Outcome
Beschreibung

0utcome : if still ongoing at the end of day 3, please record experience in the Adverse Experience Section

Datentyp

integer

Alias
UMLS CUI [1]
C1705586
Seriousness of symptoms
Beschreibung

Seriousness of symptoms

Alias
UMLS CUI-1
C0871902
UMLS CUI-2
C1457887
Do you consider any of these adverse experiences to be serious ?
Beschreibung

if Yes: Please report experience to SmithKline Beecham monitor by telephone, telex or telefax withitl 24 hours (see protocol) and complete the SAEF form.

Datentyp

boolean

Alias
UMLS CUI [1]
C1710056
V. OTHER GENERAL SYMPTOMS
Beschreibung

V. OTHER GENERAL SYMPTOMS

Alias
UMLS CUI-1
C0029625
If any general symptom other than those listed above occurred, please complete the Adverse Experience Section.
Beschreibung

Complete Adverse Experience Section

Datentyp

text

Alias
UMLS CUI [1,1]
C0029625
UMLS CUI [1,2]
C0205197
UMLS CUI [1,3]
C1521800
Administrative Data
Beschreibung

Administrative Data

Alias
UMLS CUI-1
C1320722
Date :
Beschreibung

day/month/year

Datentyp

date

Alias
UMLS CUI [1]
C0011008
Investigator Signature :
Beschreibung

Signature

Datentyp

text

Alias
UMLS CUI [1]
C2346576
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Ähnliche Modelle

Visit 6 Booster Dose General Symptoms Biologicals HepA/HepB vaccine 208127/125

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header
C1320722 (UMLS CUI-1)
Protocol
Item
Protocol
text
C1507394 (UMLS CUI [1])
Activity
Item
Activity
text
C1512346 (UMLS CUI [1])
Subject number
Item
Subject number
text
C2348585 (UMLS CUI [1])
Item Group
SOLICITED ADVERSE EXPERIENCES - GENERAL SYMPTOMS
C0877248 (UMLS CUI-1)
C0159028 (UMLS CUI-2)
Signs or symptoms since vaccine administration
Item
IV. Has the subject experienced any general solicited signs or symptoms since vaccine administration ?
boolean
C0159028 (UMLS CUI [1,1])
C2368628 (UMLS CUI [1,2])
Item Group
Temperature
C0005903 (UMLS CUI-1)
General Symptoms
Item
GENERAL SYMPTOMS
boolean
C0159028 (UMLS CUI [1])
Axillary temperature
Item
Axillary ≥ 37,5°C
boolean
C1531924 (UMLS CUI [1])
Oral temperature
Item
Oral ≥ 37,5°C
boolean
C0005903 (UMLS CUI [1,1])
C0442027 (UMLS CUI [1,2])
Rectal temperature
Item
Rectal ≥ 38°C
boolean
C0489749 (UMLS CUI [1])
Temperature Day 0
Item
Temperature Day 0
float
C0005903 (UMLS CUI [1,1])
C2826301 (UMLS CUI [1,2])
Temperature Day 0 not taken
Item
Not taken
boolean
C2826301 (UMLS CUI [1,1])
C0437722 (UMLS CUI [1,2])
Temperature Day 1
Item
Temperature Day 1
float
C0005903 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Temperature Day 1 not taken
Item
Not taken
boolean
C1442449 (UMLS CUI [1,1])
C0437722 (UMLS CUI [1,2])
Temperature Day 2
Item
Temperature Day 2
float
C0005903 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Temperature Day 2 not taken
Item
Not taken
boolean
C3842676 (UMLS CUI [1,1])
C0437722 (UMLS CUI [1,2])
Temperature Day 3
Item
Temperature Day 3
float
C0005903 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Temperature Day 3 not taken
Item
Not taken
boolean
C3842675 (UMLS CUI [1,1])
C0437722 (UMLS CUI [1,2])
Corrective therapy
Item
Corrective therapy ?
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Item
Relation
text
C0304229 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
Relation
Code List
Relation
CL Item
Related (R)
CL Item
Possibly related (PR)
CL Item
Probably unrelated (PU)
CL Item
Unrelated (U)
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Recovered (1)
CL Item
Recovered with sequelae (2)
CL Item
Ongoing (3)
CL Item
Died (4)
CL Item
Unknown (5)
Item Group
Headache
C0018681 (UMLS CUI-1)
General symptoms
Item
GENERAL SYMPTOMS
boolean
C0159028 (UMLS CUI [1])
Item
Intensity Day 0
integer
C0518690 (UMLS CUI [1,1])
C2826301 (UMLS CUI [1,2])
Intensity Day 0
Code List
Intensity Day 0
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 1
integer
C0518690 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Intensity Day 1
Code List
Intensity Day 1
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 2
integer
C0518690 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Intensity Day 2
Code List
Intensity Day 2
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 3
integer
C0518690 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Intensity Day 3
Code List
Intensity Day 3
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Corrective therapy
Item
Corrective therapy ?
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Item
Relation
text
C0304229 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
Relation
Code List
Relation
CL Item
Related (R)
CL Item
Possibly related (PR)
CL Item
Probably unrelated (PU)
CL Item
Unrelated (U)
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Recovered (1)
CL Item
Recovered with sequelae (2)
CL Item
Ongoing (3)
CL Item
Died (4)
CL Item
Unknown (5)
Item Group
Malaise
C0231218 (UMLS CUI-1)
General symptoms
Item
GENERAL SYMPTOMS
boolean
C0159028 (UMLS CUI [1])
Item
Intensity Day 0
integer
C0518690 (UMLS CUI [1,1])
C2826301 (UMLS CUI [1,2])
Intensity Day 0
Code List
Intensity Day 0
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 1
integer
C0518690 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Intensity Day 1
Code List
Intensity Day 1
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 2
integer
C0518690 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Intensity Day 2
Code List
Intensity Day 2
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 3
integer
C0518690 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Intensity Day 3
Code List
Intensity Day 3
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Corrective therapy
Item
Corrective therapy ?
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Item
Relation
text
C0304229 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
Relation
Code List
Relation
CL Item
Related (R)
CL Item
Possibly related (PR)
CL Item
Probably unrelated (PU)
CL Item
Unrelated (U)
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Recovered (1)
CL Item
Recovered with sequelae (2)
CL Item
Ongoing (3)
CL Item
Died (4)
CL Item
Unknown (5)
Item Group
Fatigue
C0015672 (UMLS CUI-1)
General symptoms
Item
GENERAL SYMPTOMS
boolean
C0159028 (UMLS CUI [1])
Item
Intensity Day 0
integer
C0518690 (UMLS CUI [1,1])
C2826301 (UMLS CUI [1,2])
Intensity Day 0
Code List
Intensity Day 0
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 1
integer
C0518690 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Intensity Day 1
Code List
Intensity Day 1
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 2
integer
C0518690 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Intensity Day 2
Code List
Intensity Day 2
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 3
integer
C0518690 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Intensity Day 3
Code List
Intensity Day 3
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Corrective therapy
Item
Corrective therapy ?
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Item
Relation
text
C0304229 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
Relation
Code List
Relation
CL Item
Related (R)
CL Item
Possibly related (PR)
CL Item
Probably unrelated (PU)
CL Item
Unrelated (U)
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Recovered (1)
CL Item
Recovered with sequelae (2)
CL Item
Ongoing (3)
CL Item
Died (4)
CL Item
Unknown (5)
Item Group
Nausea
C0027497 (UMLS CUI-1)
General symptoms
Item
GENERAL SYMPTOMS
boolean
C0159028 (UMLS CUI [1])
Item
Intensity Day 0
integer
C0518690 (UMLS CUI [1,1])
C2826301 (UMLS CUI [1,2])
Intensity Day 0
Code List
Intensity Day 0
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 1
integer
C0518690 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Intensity Day 1
Code List
Intensity Day 1
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 2
integer
C0518690 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Intensity Day 2
Code List
Intensity Day 2
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 3
integer
C0518690 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Intensity Day 3
Code List
Intensity Day 3
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Corrective therapy
Item
Corrective therapy ?
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Item
Relation
text
C0304229 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
Relation
Code List
Relation
CL Item
Related (R)
CL Item
Possibly related (PR)
CL Item
Probably unrelated (PU)
CL Item
Unrelated (U)
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Recovered (1)
CL Item
Recovered with sequelae (2)
CL Item
Ongoing (3)
CL Item
Died (4)
CL Item
Unknown (5)
Item Group
Vomiting
C0042963 (UMLS CUI-1)
General symptoms
Item
GENERAL SYMPTOMS
boolean
C0159028 (UMLS CUI [1])
Item
Intensity Day 0
integer
C0518690 (UMLS CUI [1,1])
C2826301 (UMLS CUI [1,2])
Intensity Day 0
Code List
Intensity Day 0
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 1
integer
C0518690 (UMLS CUI [1,1])
C1442449 (UMLS CUI [1,2])
Intensity Day 1
Code List
Intensity Day 1
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 2
integer
C0518690 (UMLS CUI [1,1])
C3842676 (UMLS CUI [1,2])
Intensity Day 2
Code List
Intensity Day 2
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Item
Intensity Day 3
integer
C0518690 (UMLS CUI [1,1])
C3842675 (UMLS CUI [1,2])
Intensity Day 3
Code List
Intensity Day 3
CL Item
Nihil (0)
CL Item
Mild  (1)
CL Item
Moderate  (2)
CL Item
Severe (3)
Corrective therapy
Item
Corrective therapy ?
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Item
Relation
text
C0304229 (UMLS CUI [1,1])
C0085978 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,3])
Relation
Code List
Relation
CL Item
Related (R)
CL Item
Possibly related (PR)
CL Item
Probably unrelated (PU)
CL Item
Unrelated (U)
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Recovered (1)
CL Item
Recovered with sequelae (2)
CL Item
Ongoing (3)
CL Item
Died (4)
CL Item
Unknown (5)
Item Group
Seriousness of symptoms
C0871902 (UMLS CUI-1)
C1457887 (UMLS CUI-2)
Seriousness of symptoms
Item
Do you consider any of these adverse experiences to be serious ?
boolean
C1710056 (UMLS CUI [1])
Item Group
V. OTHER GENERAL SYMPTOMS
C0029625 (UMLS CUI-1)
Complete Adverse Experience Section
Item
If any general symptom other than those listed above occurred, please complete the Adverse Experience Section.
text
C0029625 (UMLS CUI [1,1])
C0205197 (UMLS CUI [1,2])
C1521800 (UMLS CUI [1,3])
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Date
Item
Date :
date
C0011008 (UMLS CUI [1])
Signature
Item
Investigator Signature :
text
C2346576 (UMLS CUI [1])
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