Engels

Concomitant Medication Form

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Administrative data
Beschrijving

Administrative data

Subject Number
Beschrijving

Subject Number

Datatype

integer

Concomitant Medication
Beschrijving

Concomitant Medication

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

Have any medications/treatments been administered during study period?

Datatype

boolean

If Yes, please complete the following table
Beschrijving

If Yes, please complete the following table

Datatype

text

List of Medications
Beschrijving

List of Medications

Trade/Generic Name
Beschrijving

Trade/Generic Name

Datatype

text

Medical Indication
Beschrijving

Medical Indication

Datatype

text

Total daily dose
Beschrijving

Total daily dose

Datatype

text

Route
Beschrijving

Route

Datatype

text

Start date
Beschrijving

Start date

Datatype

date

End date
Beschrijving

End date

Datatype

date

Ongoing at the end of study?
Beschrijving

Ongoing at the end of study?

Datatype

boolean

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Similar models

Concomitant Medication Form

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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