Inglés

Visit 4: Concomitant Medications

1 formularios  
Administrative data
Descripción

Administrative data

Subject Number
Descripción

Subject Number

Tipo de datos

integer

Date of Visit
Descripción

Visit Date

Tipo de datos

date

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

Have any medications/treatments been administered during study period?

Tipo de datos

boolean

Medication
Descripción

Medication

Trade Name/Generic Name
Descripción

Trade Name/Generic Name

Tipo de datos

text

Total Daily Dose
Descripción

Total Daily Dose

Tipo de datos

text

Start Date
Descripción

Start Date

Tipo de datos

date

End Date
Descripción

End Date

Tipo de datos

date

Ongoing?
Descripción

Ongoing?

Tipo de datos

boolean

Medical Indication
Descripción

Medical Indication

Tipo de datos

text

If Other, specify
Descripción

If Other, specify

Tipo de datos

text

Route
Descripción

Route

Tipo de datos

text

Reminder
Descripción

Reminder

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

fill the date below

Tipo de datos

date

In case of hospitalisation, please inform
Descripción

fill the name below

Tipo de datos

text

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Similar models

Visit 4: Concomitant Medications

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative data
Subject Number
Item
Subject Number
integer
Visit Date
Item
Date of Visit
date
Have any medications/treatments been administered during study period?
Item
Have any medications/treatments been administered during study period?
boolean
Item Group
Medication
Trade Name/Generic Name
Item
Trade Name/Generic Name
text
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
Medical Indication
text
Medical Indication
Code List
Medical Indication
CL Item
Prophylactic (1)
CL Item
Other (2)
If Other, specify
Item
If Other, specify
text
Item
Route
text
Route
Code List
Route
CL Item
External (1)
CL Item
Intradermal (2)
CL Item
Inhalation (3)
CL Item
Intramuscular (4)
CL Item
Intraarticular (5)
CL Item
Intrathecal (6)
CL Item
Intravenous (7)
CL Item
Intranasal (8)
CL Item
Other (9)
CL Item
Parenteral (10)
CL Item
Oral (11)
CL Item
Rectal (12)
CL Item
Subcutaneous (13)
CL Item
Sublingual (14)
CL Item
Transdermal (15)
CL Item
Topical (16)
CL Item
Unknown (17)
CL Item
Vaginal (18)
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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