Engels

Diary Card: Concomitant Medications

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Administrative data
Beschrijving

Administrative data

Subject Number
Beschrijving

Subject Number

Datatype

integer

Dose
Beschrijving

Dose

Datatype

text

Medication
Beschrijving

Medication

Trade Name/Generic Name
Beschrijving

Trade Name/Generic Name

Datatype

text

Reason
Beschrijving

Reason

Datatype

text

Total Daily Dose?
Beschrijving

Total Daily Dose?

Datatype

text

Start Date
Beschrijving

Start Date

Datatype

date

End Date
Beschrijving

End Date

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Reminder
Beschrijving

Reminder

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

fill the date below

Datatype

date

In case of hospitalisation, please inform
Beschrijving

fill the name below

Datatype

text

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Similar models

Diary Card: Concomitant Medications

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
integer
Item
Dose
text
Dose
Code List
Dose
CL Item
Dose 1 (1)
Item Group
Medication
Trade Name/Generic Name
Item
Trade Name/Generic Name
text
Item
Reason
text
Intensity
Code List
Reason
Total Daily Dose?
Item
Total Daily Dose?
text
Start Date
Item
Start Date
date
End Date
Item
End Date
date
Ongoing?
Item
Ongoing?
boolean
Item Group
Reminder
Please do not forget to bring back the diary card on
Item
Please do not forget to bring back the diary card on
date
In case of hospitalisation, please inform
Item
In case of hospitalisation, please inform
text
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