Dermatological Examination Form

Administrative Data
Description

Administrative Data

Alias
UMLS CUI-1
C1320722
Subject Screening number
Description

Subject Screening No.

Data type

integer

Alias
UMLS CUI [1,1]
C0220908
UMLS CUI [1,2]
C0600091
Subject no.
Description

Subject Number

Data type

integer

Alias
UMLS CUI [1]
C2348585
Date of Assessment
Description

Date of Assessment

Data type

date

Alias
UMLS CUI [1]
C2985720
Actual Time
Description

Actual Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Dermatological Examination
Description

Dermatological Examination

Alias
UMLS CUI-1
C0560169
Protocol Time
Description

Protocol Time

Data type

text

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C2348563
Study Day
Description

Study Day

Data type

text

Has a Dermatological examination been performed?
Description

If no, please comment

Data type

boolean

Alias
UMLS CUI [1]
C0560169
Comment
Description

Comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Has the subject experienced any type of rash?
Description

If yes, complete the subject’s Adverse Event source document book.

Data type

boolean

Alias
UMLS CUI [1]
C0015230
How long after administration of the drug did the rash occur?
Description

Time After Administration Exanthema Occurred

Data type

text

Alias
UMLS CUI [1,1]
C0015230
UMLS CUI [1,2]
C0040223
UMLS CUI [1,3]
C0439568
In the opinion of the physician, is the subject experiencing a suspected drug induced rash?
Description

If yes, complete the “Record of Rash” page at the back of the CRF.

Data type

boolean

Alias
UMLS CUI [1]
C0015230
Was a dermatologist consulted?
Description

Dermatologist Consulted

Data type

boolean

Alias
UMLS CUI [1,1]
C0259831
UMLS CUI [1,2]
C0009818
Physician's Signature
Description

Physician's Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Conclusion
Description

Conclusion

Alias
UMLS CUI-1
C1707478
Staff initials
Description

Staff initials

Data type

text

Alias
UMLS CUI [1,1]
C2986440
UMLS CUI [1,2]
C1552089
Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008

Similar models

Dermatological Examination Form

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Subject Screening No.
Item
Subject Screening number
integer
C0220908 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Subject Number
Item
Subject no.
integer
C2348585 (UMLS CUI [1])
Date of Assessment
Item
Date of Assessment
date
C2985720 (UMLS CUI [1])
Actual Time
Item
Actual Time
time
C0040223 (UMLS CUI [1])
Item Group
Dermatological Examination
C0560169 (UMLS CUI-1)
Item
Protocol Time
text
C0040223 (UMLS CUI [1,1])
C2348563 (UMLS CUI [1,2])
Code List
Protocol Time
CL Item
Pre Dose (Pre Dose)
CL Item
48h00 post dose (48h00 post dose)
CL Item
24h00 post dose (24h00 post dose)
CL Item
216h00 post dose (216h00 post dose)
Item
Study Day
text
Code List
Study Day
CL Item
Day 1 (Day 1)
CL Item
Day 3 (Day 3)
CL Item
Day 2 (Day 2)
CL Item
Day 10 (Day 10)
Dermatological Examination Performed
Item
Has a Dermatological examination been performed?
boolean
C0560169 (UMLS CUI [1])
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Rashes
Item
Has the subject experienced any type of rash?
boolean
C0015230 (UMLS CUI [1])
Time After Administration Exanthema Occurred
Item
How long after administration of the drug did the rash occur?
text
C0015230 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
C0439568 (UMLS CUI [1,3])
Sespected Drug induced Rash
Item
In the opinion of the physician, is the subject experiencing a suspected drug induced rash?
boolean
C0015230 (UMLS CUI [1])
Dermatologist Consulted
Item
Was a dermatologist consulted?
boolean
C0259831 (UMLS CUI [1,1])
C0009818 (UMLS CUI [1,2])
Physician's Signature
Item
Physician's Signature
text
C1519316 (UMLS CUI [1])
Item Group
Conclusion
C1707478 (UMLS CUI-1)
Staff initials
Item
Staff initials
text
C2986440 (UMLS CUI [1,1])
C1552089 (UMLS CUI [1,2])
Date
Item
Date
date
C0011008 (UMLS CUI [1])