Englisch

Additional Forms

1 Formulare  
  1. StudyEvent: ODM
    1. Additional Forms
Home Pregnancy Test Result
Beschreibung

Home Pregnancy Test Result

Alias
UMLS CUI-1
C0032976
Sample date
Beschreibung

sample date pregnancy test

Datentyp

date

Alias
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C0011008
Result
Beschreibung

result pregnancy test

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C1274040
Prior and Concomitant Medications
Beschreibung

Prior and Concomitant Medications

Alias
UMLS CUI-1
C2826257
UMLS CUI-2
C2347852
Drug Name (trade name preferred)
Beschreibung

drug name

Datentyp

text

Alias
UMLS CUI [1]
C0013227
Indication (or symptoms in the absence of diagnosis)
Beschreibung

indication for concomitant medication

Datentyp

text

Alias
UMLS CUI [1]
C2826696
Date started
Beschreibung

concomitant medication start date

Datentyp

date

Alias
UMLS CUI [1]
C2826734
Continuing?
Beschreibung

concomitant medication continuation status

Datentyp

boolean

Alias
UMLS CUI [1]
C2826666
Date Stopped
Beschreibung

concomitant medication end date

Datentyp

date

Alias
UMLS CUI [1]
C2826744
Adverse Events
Beschreibung

Adverse Events

Alias
UMLS CUI-1
C0877248
Adverse Event
Beschreibung

adverse event

Datentyp

text

Alias
UMLS CUI [1]
C0877248
Date of Onset
Beschreibung

date of onset

Datentyp

date

Alias
UMLS CUI [1]
C2985916
Frequency
Beschreibung

frequency of adverse event

Datentyp

date

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0439603
Maximum Intensity
Beschreibung

maximum intensity of adverse event

Datentyp

text

Alias
UMLS CUI [1]
C1710066
Outcome
Beschreibung

outcome of adverse event

Datentyp

text

Alias
UMLS CUI [1]
C1705586
Date Of Resolution
Beschreibung

date of adverse event resolution

Datentyp

date

Alias
UMLS CUI [1]
C2985918
Action Taken With IP
Beschreibung

action taken with investigational product

Datentyp

text

Alias
UMLS CUI [1,1]
C1704758
UMLS CUI [1,2]
C0877248
Withdrawn Due to AE?
Beschreibung

If subject is withdrawn due to Adverse Event, complete the Early Withdrawal visit.

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C0877248
Relationship to Investigational Drug
Beschreibung

Is there a reasonable possibility that the Adverse Event may have been caused by the investigational product?

Datentyp

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0013230
UMLS CUI [1,3]
C0439849
Serious Adverse Event?
Beschreibung

If this is a Serious Adverse Event, complete the Serious Adverse Event paper form and follow instructions.

Datentyp

boolean

Alias
UMLS CUI [1]
C1519255
Repeat 12-lead electrocardiogram
Beschreibung

Repeat 12-lead electrocardiogram

Alias
UMLS CUI-1
C0430456
Date of ECG
Beschreibung

date of ecg

Datentyp

date

Alias
UMLS CUI [1]
C2826640
Result of ECG
Beschreibung

If 'Abnormal - clinically significant' please record on the Current Medical Conditions or the Adverse Events panel as appropriate.

Datentyp

text

Alias
UMLS CUI [1]
C0438154
Repeat Laboratory Tests
Beschreibung

Repeat Laboratory Tests

Alias
UMLS CUI-1
C0022885
Was this a blood or a urine sample?
Beschreibung

blood sample | urine sample

Datentyp

text

Alias
UMLS CUI [1]
C1277698
UMLS CUI [2]
C0200354
Date of Sample
Beschreibung

date of sample

Datentyp

date

Alias
UMLS CUI [1]
C1302413
After reviewing the laboratory results, are there any clinically significant abnormalities?
Beschreibung

If 'Yes', please record the findings and/or diagnosis on the Current Medical Conditions or Adverse Events panel as appropriat

Datentyp

boolean

Alias
UMLS CUI [1]
C1853129
Investigational Product
Beschreibung

Investigational Product

Alias
UMLS CUI-1
C0304229
Visit at Which Medication Was Returned
Beschreibung

return of investigational product

Datentyp

date

Alias
UMLS CUI [1,1]
C0947323
UMLS CUI [1,2]
C0304229
Bottle A (tablets) or Bottle B (capsules)
Beschreibung

Investigational Product

Datentyp

text

Alias
UMLS CUI [1]
C0304229
Dose level
Beschreibung

Dose level

Datentyp

text

Alias
UMLS CUI [1]
C0178602
Start Date
Beschreibung

investigational product start date

Datentyp

date

Alias
UMLS CUI [1,1]
C0808070
UMLS CUI [1,2]
C0304229
End Date
Beschreibung

investigational product end date

Datentyp

date

Alias
UMLS CUI [1,1]
C0806020
UMLS CUI [1,2]
C0304229
Number dispensed
Beschreibung

investigational product number dispensed

Datentyp

integer

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0805077
Number Returned
Beschreibung

investigational product number returned

Datentyp

integer

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C2699071
Interruption >=4 consecutive days
Beschreibung

The subject should be withdrawn from the study if there is an interruption of >=4 consecutive days or if compliance is <75% or >125%

Datentyp

boolean

Alias
UMLS CUI [1,1]
C3843191
UMLS CUI [1,2]
C1512900
Comments
Beschreibung

Comments

Comments
Beschreibung

Research Comments

Datentyp

text

Alias
UMLS CUI [1]
C0947611
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Ähnliche Modelle

Additional Forms

1 Formulare
  1. StudyEvent: ODM
    1. Additional Forms
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Home Pregnancy Test Result
C0032976 (UMLS CUI-1)
sample date pregnancy test
Item
Sample date
date
C0032976 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
result pregnancy test
Item
Result
boolean
C0032976 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])
Item Group
Prior and Concomitant Medications
C2826257 (UMLS CUI-1)
C2347852 (UMLS CUI-2)
drug name
Item
Drug Name (trade name preferred)
text
C0013227 (UMLS CUI [1])
indication for concomitant medication
Item
Indication (or symptoms in the absence of diagnosis)
text
C2826696 (UMLS CUI [1])
concomitant medication start date
Item
Date started
date
C2826734 (UMLS CUI [1])
concomitant medication continuation status
Item
Continuing?
boolean
C2826666 (UMLS CUI [1])
concomitant medication end date
Item
Date Stopped
date
C2826744 (UMLS CUI [1])
Item Group
Adverse Events
C0877248 (UMLS CUI-1)
adverse event
Item
Adverse Event
text
C0877248 (UMLS CUI [1])
date of onset
Item
Date of Onset
date
C2985916 (UMLS CUI [1])
frequency of adverse event
Item
Frequency
date
C0877248 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
maximum intensity of adverse event
Item
Maximum Intensity
text
C1710066 (UMLS CUI [1])
outcome of adverse event
Item
Outcome
text
C1705586 (UMLS CUI [1])
date of adverse event resolution
Item
Date Of Resolution
date
C2985918 (UMLS CUI [1])
action taken with investigational product
Item
Action Taken With IP
text
C1704758 (UMLS CUI [1,1])
C0877248 (UMLS CUI [1,2])
withdrawn due to adverse event
Item
Withdrawn Due to AE?
boolean
C0422727 (UMLS CUI [1,1])
C0877248 (UMLS CUI [1,2])
relation of investigational drug to adverse event
Item
Relationship to Investigational Drug
text
C0877248 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
serious adverse event
Item
Serious Adverse Event?
boolean
C1519255 (UMLS CUI [1])
Item Group
Repeat 12-lead electrocardiogram
C0430456 (UMLS CUI-1)
date of ecg
Item
Date of ECG
date
C2826640 (UMLS CUI [1])
result of ecg
Item
Result of ECG
text
C0438154 (UMLS CUI [1])
Item Group
Repeat Laboratory Tests
C0022885 (UMLS CUI-1)
blood sample | urine sample
Item
Was this a blood or a urine sample?
text
C1277698 (UMLS CUI [1])
C0200354 (UMLS CUI [2])
date of sample
Item
Date of Sample
date
C1302413 (UMLS CUI [1])
laboratory abnormalities
Item
After reviewing the laboratory results, are there any clinically significant abnormalities?
boolean
C1853129 (UMLS CUI [1])
Item Group
Investigational Product
C0304229 (UMLS CUI-1)
return of investigational product
Item
Visit at Which Medication Was Returned
date
C0947323 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
Item
Bottle A (tablets) or Bottle B (capsules)
text
C0304229 (UMLS CUI [1])
Investigational Product
Code List
Bottle A (tablets) or Bottle B (capsules)
CL Item
tablets (A)
CL Item
capsules (B)
Dose level
Item
Dose level
text
C0178602 (UMLS CUI [1])
investigational product start date
Item
Start Date
date
C0808070 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
investigational product end date
Item
End Date
date
C0806020 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
investigational product number dispensed
Item
Number dispensed
integer
C0304229 (UMLS CUI [1,1])
C0805077 (UMLS CUI [1,2])
investigational product number returned
Item
Number Returned
integer
C0304229 (UMLS CUI [1,1])
C2699071 (UMLS CUI [1,2])
investigational product intake interrupted
Item
Interruption >=4 consecutive days
boolean
C3843191 (UMLS CUI [1,1])
C1512900 (UMLS CUI [1,2])
Item Group
Comments
Research Comments
Item
Comments
text
C0947611 (UMLS CUI [1])
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