Demography
Date of Birth
date
Gender
integer
Childbearing potential
integer
Ethnicity
integer
Geographic ancestry
integer
Cohort
Vital Signs
Actual date of vital signs
date
Actual time of vital signs
time
Height
integer
Weight
float
Body mass index
float
Position
integer
Systolic Blood Pressure
integer
Diastolic Blood Pressure
integer
Heart rate
integer
Respiration rate
integer
Temperature
float
12-lead ECG
Start Date of ECG
date
Start Time of ECG
time
Heart Rate
integer
PR Interval
float
QRS Duration
float
Uncorrected QT Interval
float
Method of QTC Measurement
integer
QTcB
float
QTcF
float
RR interval
float
(complete the ECG abnormality form for all clinically significant abnormalities, and additionally complete the AE form if the abnormality meets the protocol definition for an AE)
integer
Eligibility Question
If no, please select all boxes corresponding to violations of any inclusion/exclusion criteria
boolean
Inclusion Criteria
boolean
Inclusion criteria
boolean
Inclusion criteria
boolean
Inclusion criteria
boolean
Inclusion criteria
boolean
Inclusion criteria
boolean
Inclusion criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
text
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
text
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
Exclusion Criteria
boolean
The following apply to PET subjects only:
boolean
The following apply to PET subjects only:
boolean
The following apply to PET subjects only:
boolean
The following apply to PET subjects only:
text
Subject Identification
Holter ECG Results
Start Date Holter ECG
date
Start Time Holter ECG
time
Stop Date Holter ECG
date
Stop Time Holter ECG
time
Interpretation of Holter ECG
integer
INCLUDE ABNORMALITIES FOR HOLTER AT THIS VISIT ONLY
integer
morphology
text
abnormal rhythm
text
conduction
text
myocardial infarction
text
depolarisation/repolarisation
text
Other abnormality Holter ECG
text
Menstrual cycle profile
Date of start of last menstrual period
date
Date of end of last menstrual period
date
Haematology
Day Month Year Hr : Min (00:00 - 23:59)
datetime
Fasting
boolean
Type of result
integer
White blood cell count
text
Red blood cell count
text
Haemoglobin
text
Haematocrit
text
Neutrophil count
text
Lymphocyte count
text
Monocyte count
text
Eosinophil count
text
Basophil count
text
Platelet count
text
Reticulocyte count
text
Mean cell volume
text
Mean cell haemoglobin
text
Mean cell haemoglobin concentration
text
Clinical Chemistry
Date and time sample taken
datetime
Fasting
boolean
Type of result
integer
Alkaline phosphatase
text
Alanine transaminase
text
Total Bilirubin
text
Direct Bilirubin
text
Glucose
text
Gamma-glutamyl transpeptidase
text
Total protein
text
Albumin
text
Potassium
text
Sodium
text
Chloride
text
Urea
text
Creatinine
text
Calcium
text
Bicarbonate
text
Triglycerides
text
Cholesterol
text
LDL
text
HDL
text
Uric Acid
text
Alkaline Phosphatase
text
Urinalysis - Local
Date sample taken
date
Time sample taken
time
If positive, record results of individual tests below.
integer
If Yes, provide details on the MICROSCOPY form
boolean
Urinalysis - Local: Dipstick Details
Type of result
integer
Urine Protein
text
Urine Glucose
text
Urine Ketones
text
Urine Blood
text
Urine pH
text
Urine Specific Gravity
text
Urinalysis - Local: Microscopy Details
Type of result
integer
White blood cells
text
Red Blood Cells
text
Hyaline casts
text
Cellular casts
text
Local Laboratory - Clinical Chemistry
Date and time sample taken
datetime
Fasting
boolean
Type of result
integer
TSH
text
GH
text
Total Testosterone
text
Free Testosterone
text
LH
text
FSH
text
(Females only)
text
Prolactin
text
Randomisation
Randomisation
boolean
Randomisation number
integer
Date of randomisation
date