Inglés

Medical History

1 formularios  
  1. StudyEvent: ODM
    1. Medical History
Administrative data
Descripción

Administrative data

Visit Number
Descripción

Visit Number

Tipo de datos

text

Date of Visit
Descripción

Date of Visit

Tipo de datos

date

Subject Number
Descripción

Subject Number

Tipo de datos

integer

General Medical History / Physical Examination
Descripción

General Medical History / Physical Examination

Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study?
Descripción

Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study?

Tipo de datos

text

Cutaneous
Descripción

Cutaneous

Tipo de datos

text

Diagnosis
Descripción

Diagnosis

Tipo de datos

text

Eyes
Descripción

Eyes

Tipo de datos

text

Diagnosis
Descripción

Diagnosis

Tipo de datos

text

Ears-Nose-Throat
Descripción

Ears-Nose-Throat

Tipo de datos

text

Diagnosis
Descripción

Diagnosis

Tipo de datos

text

Cardiovascular
Descripción

Cardiovascular

Tipo de datos

text

Diagnosis
Descripción

Diagnosis

Tipo de datos

text

Respiratory
Descripción

Respiratory

Tipo de datos

text

Gastrointestinal
Descripción

Gastrointestinal

Tipo de datos

text

Muskuloskeletal
Descripción

Muskuloskeletal

Tipo de datos

text

Neurological
Descripción

Neurological

Tipo de datos

text

Genitourinary
Descripción

Genitourinary

Tipo de datos

text

Haematology
Descripción

Haematology

Tipo de datos

text

Allergies
Descripción

Allergies

Tipo de datos

text

Endocrine
Descripción

Endocrine

Tipo de datos

text

Other, specify
Descripción

Other, specify

Tipo de datos

text

Concomitant Medications
Descripción

Concomitant Medications

Please report medication(s) as specified in the protocol and fill in the Medication section
Descripción

Please report medication(s) as specified in the protocol and fill in the Medication section

Tipo de datos

text

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Similar models

Medical History

1 formularios
  1. StudyEvent: ODM
    1. Medical History
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative data
Item
Visit Number
text
Visit Number
Code List
Visit Number
CL Item
Visit 1 (1)
Date of Visit
Item
Date of Visit
date
Subject Number
Item
Subject Number
integer
Item Group
General Medical History / Physical Examination
Item
Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study?
text
Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study?
Code List
Are you aware of any pre-existing conditions or signs and/or symptoms present in the subject prior to the start of the study?
CL Item
No (1)
CL Item
Yes -> please tick appropriate box(es) and give diagnosis (2)
Item
Cutaneous
text
Cutaneous
Code List
Cutaneous
CL Item
Current (1)
CL Item
Past (2)
Diagnosis
Item
Diagnosis
text
Item
Eyes
text
Eyes
Code List
Eyes
CL Item
Current (1)
CL Item
Past (2)
Diagnosis
Item
Diagnosis
text
Item
Ears-Nose-Throat
text
Ears-Nose-Throat
Code List
Ears-Nose-Throat
CL Item
Current (1)
CL Item
Past (2)
Diagnosis
Item
Diagnosis
text
Item
Cardiovascular
text
Cardiovascular
Code List
Cardiovascular
CL Item
Current (1)
CL Item
Past (2)
Diagnosis
Item
Diagnosis
text
Item
Respiratory
text
Respiratory
Code List
Respiratory
CL Item
Current (1)
CL Item
Past (2)
Item
Gastrointestinal
text
Gastrointestinal
Code List
Gastrointestinal
CL Item
Current (1)
CL Item
Past (2)
Item
Muskuloskeletal
text
Muskuloskeletal
Code List
Muskuloskeletal
CL Item
Current (1)
CL Item
Past (2)
Item
Neurological
text
Neurological
Code List
Neurological
CL Item
Current (1)
CL Item
Past (2)
Item
Genitourinary
text
Genitourinary
Code List
Genitourinary
CL Item
Current (1)
CL Item
Past (2)
Item
Haematology
text
Haematology
Code List
Haematology
CL Item
Current (1)
CL Item
Past (2)
Item
Allergies
text
Allergies
Code List
Allergies
CL Item
Current (1)
CL Item
Past (2)
Item
Endocrine
text
Endocrine
Code List
Endocrine
CL Item
Current (1)
CL Item
Past (2)
Other, specify
Item
Other, specify
text
Item Group
Concomitant Medications
Please report medication(s) as specified in the protocol and fill in the Medication section
Item
Please report medication(s) as specified in the protocol and fill in the Medication section
text
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