Electrocardiogram (12 lead)
Dato of ECG
date
If ’Yes’, please record details in the Baseline Signs and Symptoms and/or SAE section at the back of this book and exclude the patient from the study.
integer
Laboratory evaluation
Date of sample
date
If ‘Yes’, please record the findings and/or diagnosis in the Baseline Signs and Symptoms and/or SAE section at the back of this book and exclude the patient from the study.
integer