English

Diary Card: Unsolicited Symptoms (All Groups)

1 forms  
Administrative data
Description

Administrative data

Dose Number
Description

Dose Number

Data type

text

Subject Number
Description

Subject Number

Data type

integer

Please do not forget to bring back the diary card on
Description

fill the date below

Data type

date

Other Symptoms (Day 0-42)
Description

Other Symptoms (Day 0-42)

Symptom
Description

Symptom

Data type

integer

Description
Description

Description

Data type

text

Intensity
Description

Intensity

Data type

text

Start day
Description

Start day

Data type

date

End date
Description

End date

Data type

date

Ongoing?
Description

Ongoing?

Data type

boolean

Medication
Description

Medication

Trade/Generic name
Description

Please fill in below if any medication has been taken since the vaccination

Data type

text

Reason
Description

Reason

Data type

text

Total daily dose
Description

Total daily dose

Data type

text

Start date
Description

Start date

Data type

date

End date
Description

End date

Data type

date

Still taking medication?
Description

Still taking medication?

Data type

boolean

Back to the top of the page

Similar models

Diary Card: Unsolicited Symptoms (All Groups)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative data
Item
Dose Number
text
Dose Number
Code List
Dose Number
CL Item
Dose 1 (1)
Subject Number
Item
Subject Number
integer
Please do not forget to bring back the diary card on
Item
Please do not forget to bring back the diary card on
date
Item Group
Other Symptoms (Day 0-42)
Symptom
Item
Symptom
integer
Description
Item
Description
text
Item
Intensity
text
Intensity
Code List
Intensity
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Start day
Item
Start day
date
End date
Item
End date
date
Ongoing?
Item
Ongoing?
boolean
Item Group
Medication
Trade/Generic name
Item
Trade/Generic name
text
Reason
Item
Reason
text
Total daily dose
Item
Total daily dose
text
Start date
Item
Start date
date
End date
Item
End date
date
Still taking medication?
Item
Still taking medication?
boolean
Back to the top of the page