End of Study
Item
Did the patient complete the study according to the protocol?
boolean
C2348568 (UMLS CUI [1,1])
C0444496 (UMLS CUI [1,2])
Item
If ’No’, please mark the primary cause of withdrawal. (Mark one box only)
integer
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Code List
If ’No’, please mark the primary cause of withdrawal. (Mark one box only)
CL Item
Adverse experience (please complete AE page) (1)
CL Item
Insufficient therapeutic effect (2)
CL Item
Protocol deviation (including non-compliance) (3)
CL Item
Lost to follow-up (4)
primary cause of withdrawal
Item
Primary cause of withdrawal: If 'Other', please specify
text
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Investigator’s Signature
Item
Investigator’s Signature
text
C2346576 (UMLS CUI [1])
Investigator’s Signature Date
Item
Investigator’s Signature Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])