Engelsk

Concomitant Medication Form

1 Formulär  
Administrative data
Beskrivning

Administrative data

Subject Number
Beskrivning

Subject Number

Datatyp

integer

Concomitant Medication
Beskrivning

Concomitant Medication

Have any medications/treatments been administered during study period?
Beskrivning

Have any medications/treatments been administered during study period?

Datatyp

boolean

If Yes, please complete the following table
Beskrivning

If Yes, please complete the following table

Datatyp

text

List of Medications
Beskrivning

List of Medications

Trade/Generic Name
Beskrivning

Trade/Generic Name

Datatyp

text

Medical Indication
Beskrivning

Medical Indication

Datatyp

text

Total daily dose
Beskrivning

Total daily dose

Datatyp

text

Route
Beskrivning

Route

Datatyp

text

Start date
Beskrivning

Start date

Datatyp

date

End date
Beskrivning

End date

Datatyp

date

Ongoing at the end of study?
Beskrivning

Ongoing at the end of study?

Datatyp

boolean

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Similar models

Concomitant Medication Form

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
integer
Item Group
Concomitant Medication
Have any medications/treatments been administered during study period?
Item
Have any medications/treatments been administered during study period?
boolean
If Yes, please complete the following table
Item
If Yes, please complete the following table
text
Item Group
List of Medications
Trade/Generic Name
Item
Trade/Generic Name
text
Item
Medical Indication
text
Medical Indication
Code List
Medical Indication
CL Item
Prophylactic (1)
Total daily dose
Item
Total daily dose
text
Route
Item
Route
text
Start date
Item
Start date
date
End date
Item
End date
date
Ongoing at the end of study?
Item
Ongoing at the end of study?
boolean
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