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Concomitant Medication Form

1 forms  
Administrative data
Description

Administrative data

Subject Number
Description

Subject Number

Data type

integer

Concomitant Medication
Description

Concomitant Medication

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

Have any medications/treatments been administered during study period?

Data type

boolean

If Yes, please complete the following table
Description

If Yes, please complete the following table

Data type

text

List of Medications
Description

List of Medications

Trade/Generic Name
Description

Trade/Generic Name

Data type

text

Medical Indication
Description

Medical Indication

Data type

text

Total daily dose
Description

Total daily dose

Data type

text

Route
Description

Route

Data type

text

Start date
Description

Start date

Data type

date

End date
Description

End date

Data type

date

Ongoing at the end of study?
Description

Ongoing at the end of study?

Data type

boolean

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Similar models

Concomitant Medication Form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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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