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])
Item
Organ system
integer
C0678852 (UMLS CUI [1])
CL Item
Ears-Nose-Throat (6)
CL Item
Cardiovascular (2)
CL Item
Gastrointestinal (1)
CL Item
Muskuloskeletal (7)
CL Item
Genitourinary (12)
CL Item
Other (specify) (99)
Item
Ongoing disease?
text
C0699749 (UMLS CUI [1,1])
C0037274 (UMLS CUI [1,2])
Code List
Ongoing disease?
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])
Blood sample
Item
Has a blood sample been taken ?
boolean
C0005834 (UMLS CUI [1,1])
C1277698 (UMLS CUI [1,2])
Date of blood sample
Item
Please complete only if different from visit date:
date
C0005834 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])