Medical History
Item
Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study ? Please tick appropriate box(es) and give diagnosis
boolean
C0262926 (UMLS CUI [1])
C0205476 (UMLS CUI [2,1])
C0348080 (UMLS CUI [2,2])
C1457887 (UMLS CUI [3])
Cutaneous Disease
Item
[10] Cutaneous Diagnosis
text
C0037274 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[10] Cutaneous
text
C0699749 (UMLS CUI [1,1])
C0037274 (UMLS CUI [1,2])
CL Item
Current (Current)
Eye Disease
Item
[5] Eyes Diagnosis
text
C0015397 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[5] Eyes
text
C0699749 (UMLS CUI [1,1])
C0015397 (UMLS CUI [1,2])
CL Item
Current (Current)
Ears-Nose-Throat Disease
Item
[6] Ears-Nose-Throat Diagnosis
text
C0395797 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[6] Ears-Nose-Throat
text
C0699749 (UMLS CUI [1,1])
C0395797 (UMLS CUI [1,2])
Code List
[6] Ears-Nose-Throat
CL Item
Current (Current)
Cardiovascular disorder
Item
[2] Cardiovascular Diagnosis
text
C0007222 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[2] Cardiovascular
text
C0699749 (UMLS CUI [1,1])
C0007222 (UMLS CUI [1,2])
Code List
[2] Cardiovascular
CL Item
Current (Current)
Respiratory disorder
Item
[3] Respiratory Diagnosis
text
C0035204 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[3] Respiratory
text
C0699749 (UMLS CUI [1,1])
C0035204 (UMLS CUI [1,2])
Code List
[3] Respiratory
CL Item
Current (Current)
Gastrointestinal disorder
Item
[1] Gastrointestinal Diagnosis
text
C0017178 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[1] Gastrointestinal
text
C0699749 (UMLS CUI [1,1])
C0017178 (UMLS CUI [1,2])
Code List
[1] Gastrointestinal
CL Item
Current (Current)
Muskuloskeletal disorder
Item
[7] Muskuloskeletal Diagnosis
text
C0026857 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[7] Muskuloskeletal
text
C0699749 (UMLS CUI [1,1])
C0026857 (UMLS CUI [1,2])
Code List
[7] Muskuloskeletal
CL Item
Current (Current)
Neurological disorder
Item
[8] Neurological Diagnosis
text
C0027765 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[8] Neurological
text
C0699749 (UMLS CUI [1,1])
C0027765 (UMLS CUI [1,2])
Code List
[8] Neurological
CL Item
Current (Current)
Genitourinary Disorder
Item
[12] Genitourinary Diagnosis
text
C0080276 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[12] Genitourinary
text
C0699749 (UMLS CUI [1,1])
C0080276 (UMLS CUI [1,2])
Code List
[12] Genitourinary
CL Item
Current (Current)
Haematological disease
Item
[11] Haematology Diagnosis
text
C0018939 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[11] Haematology
text
C0699749 (UMLS CUI [1,1])
C0018939 (UMLS CUI [1,2])
Code List
[11] Haematology
CL Item
Current (Current)
Hypersensitivity
Item
[4] Allergies Diagnosis
text
C0020517 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[4] Allergies
text
C0699749 (UMLS CUI [1,1])
C0020517 (UMLS CUI [1,2])
CL Item
Current (Current)
Endocrine Disorder
Item
[9] Endocrine Diagnosis
text
C0014130 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
[9] Endocrine
text
C0699749 (UMLS CUI [1,1])
C0014130 (UMLS CUI [1,2])
CL Item
Current (Current)
Other Diagnosis
Item
[99] Other (specify) Diagnosis
text
C2359476 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Item
[99] Other (specify)
text
C0699749 (UMLS CUI [1,1])
C2359476 (UMLS CUI [1,2])
Code List
[99] Other (specify)
CL Item
Current (Current)
Item
Is the subject's previous vaccination status against Hib and DTP known?
text
C1443394 (UMLS CUI [1,1])
C0199818 (UMLS CUI [1,2])
C1443394 (UMLS CUI [2,1])
C0012559 (UMLS CUI [2,2])
Code List
Is the subject's previous vaccination status against Hib and DTP known?
CL Item
Unknown (Unknown)
CL Item
Yes, if yes, please complete the following table (Yes, if yes, please complete the following table)
Trade Name of Vaccination
Item
Trade / Generic Name of Vaccination
text
C0027365 (UMLS CUI [1,1])
C0042210 (UMLS CUI [1,2])
Dose Number
Item
Dose Number of Vaccination
text
C1115464 (UMLS CUI [1,1])
C0042210 (UMLS CUI [1,2])
Date of vaccination
Item
Estimated date of vaccine* * Enter approximate date in case the exact date is unknown
date
C0011008 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
Investigator Use
Item
For GSK
text
C0008961 (UMLS CUI [1,1])
C0457083 (UMLS CUI [1,2])
Item
Previous history of Hib disease:
text
C2028293 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
Code List
Previous history of Hib disease:
CL Item
Unknown (Unknown)
CL Item
Yes (Please complete date(s) ) (Yes (Please complete date(s) ))
Date of Hib Disease
Item
Previous history of Hib disease: Estimated date* * Enter approximate date in case the exact date is unknown
date
C2028293 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Previous history of diphtheria disease:
text
C0012546 (UMLS CUI [1,1])
C3714514 (UMLS CUI [1,2])
C0262926 (UMLS CUI [1,3])
Code List
Previous history of diphtheria disease:
CL Item
Unknown (Unknown)
CL Item
Yes (Please complete date(s) ) (Yes (Please complete date(s) ))
Date of Diphteria disease
Item
Previous history of diphtheria disease: Estimated date* * Enter approximate date in case the exact date is unknown
date
C0011008 (UMLS CUI [1,1])
C0012546 (UMLS CUI [1,2])
C3714514 (UMLS CUI [1,3])
Item
Previous history of tetanus disease:
text
C0039614 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
Code List
Previous history of tetanus disease:
CL Item
Unknown (Unknown)
CL Item
Yes (Please complete date(s) ) (Yes (Please complete date(s) ))
Date of Tetanus disease
Item
Previous history of tetanus disease: Estimated date* * Enter approximate date in case the exact date is unknown
date
C0039614 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item
Previous history of pertussis disease:
text
C0043167 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
Code List
Previous history of pertussis disease:
CL Item
Unknown (Unknown)
CL Item
Yes (Please complete date(s) ) (Yes (Please complete date(s) ))
Date of Pertussis disease
Item
Previous history of pertussis disease: Estimated date* * Enter approximate date in case the exact date is unknown
date
C0043167 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Has a blood sample been taken ?
text
C0005834 (UMLS CUI [1,1])
C1277698 (UMLS CUI [1,2])
Code List
Has a blood sample been taken ?
Date of blood sample
Item
Please complete only if different from visit date:
date
C0005834 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])