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Concomitant Medications Form

1 forms  
Concomitant Medication Details
Description

Concomitant Medication Details

Sequence Number
Description

Sequence Number

Data type

text

Drug Name
Description

Trade Name Preferred

Data type

text

Unit Dose
Description

Unit Dose

Data type

integer

Units
Description

Units

Data type

text

Frequency
Description

Frequency

Data type

text

Route
Description

Route

Data type

text

Reason for Medication
Description

Reason for Medication

Data type

text

Generic dispensed?
Description

Generic dispensed?

Data type

boolean

Prescription or OTC?
Description

Prescription or OTC?

Data type

text

Start Date
Description

Start Date

Data type

date

Taken prior to study?
Description

Taken prior to study?

Data type

boolean

Ongoing?
Description

Ongoing?

Data type

boolean

If NO, record the End Date
Description

If NO, record the End Date

Data type

date

Device Used to Administer Medication
Description

Device Used to Administer Medication

Data type

text

Total Daily Dose
Description

Total Daily Dose

Data type

text

Was drug administered for an exacerbation?
Description

Was drug administered for an exacerbation?

Data type

boolean

Was drug administered as a rescue medication?
Description

Was drug administered as a rescue medication?

Data type

boolean

Cumulative Dose Used?
Description

Cumulative Dose Used?

Data type

text

Was drug ever used?
Description

Was drug ever used?

Data type

boolean

Total duration
Description

Total duration

Data type

text

Duration Unit
Description

Duration Unit

Data type

text

Medication Type
Description

Medication Type

Data type

text

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Similar models

Concomitant Medications Form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Concomitant Medication Details
Sequence Number
Item
Sequence Number
text
Drug Name
Item
Drug Name
text
Unit Dose
Item
Unit Dose
integer
Units
Item
Units
text
Frequency
Item
Frequency
text
Route
Item
Route
text
Reason for Medication
Item
Reason for Medication
text
Generic dispensed?
Item
Generic dispensed?
boolean
Item
Prescription or OTC?
text
Prescription of OTC?
Code List
Prescription or OTC?
CL Item
Prescription (1)
CL Item
OTC (2)
Start Date
Item
Start Date
date
Taken prior to study?
Item
Taken prior to study?
boolean
Ongoing?
Item
Ongoing?
boolean
If NO, record the End Date
Item
If NO, record the End Date
date
Device Used to Administer Medication
Item
Device Used to Administer Medication
text
Total Daily Dose
Item
Total Daily Dose
text
Was drug administered for an exacerbation?
Item
Was drug administered for an exacerbation?
boolean
Was drug administered as a rescue medication?
Item
Was drug administered as a rescue medication?
boolean
Cumulative Dose Used?
Item
Cumulative Dose Used?
text
Was drug ever used?
Item
Was drug ever used?
boolean
Total duration
Item
Total duration
text
Item
Duration Unit
text
Duration Unit
Code List
Duration Unit
CL Item
Days (1)
CL Item
Months (2)
CL Item
Weeks (3)
CL Item
Years (4)
Item
Medication Type
text
Medication Type
Code List
Medication Type
CL Item
Non-Asthma (1)
CL Item
Asthma (2)
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