Administrative data
Site
text
Subject
Visit Name
Status
Doc №
integer
blank page?
boolean
Prior and Concomitant Medications/Non-Drug Therapies
Concomitant Medication
including procedures and surgeries
Trade name preferred
Unit Dose
Unit
Frequency
Route
If AE/SAE enter Event Term
AE/SAE Event Number
Start date
date
Stop date
Ongoing?
Taken prior to study?
PGx-Pharmacogenetic Research Consent
Has the informed consent been obtained for PGx-Pharmacogenetic Research?
Date informed consent obtained
If no consent obtained, check the reason
If other, specify
Blood Sample
Has a blood sample been collected for PGx research?
Record the date sample taken
If no, check the reason
If Other, specify