IMD Report
Has any confirmed or probable Immune Mediated Disease occurred during the study?
boolean
If Immune Mediated Diasease occured during study, tick the disease category
text
General Medical History
Are you aware of any pre-existing conditions present in Patient or in close family (father, mother or sister/brother) prior the start of the study?
boolean
General Medical History
Diagnosis
text
Pre-existing conditions present in Patient or in close family
integer
Diagnosis status
integer
Relevant risk factors
Are you aware of any other pre-existing conditions in other family members or of relevant risk factors (occupational, life style,…) in the Patient?
boolean
Pre-existing conditions or Risk factors details
text
Neurological Events
Neurological Event Diagnosis
integer
Specify other diagnosis
text
In case of serious adverse event
integer
In case of non-serious adverse event
integer
Date of final diagnosis:
date
Neurological Events - Signs and Symptoms
Neurological Events - Signs and Symptoms
integer
Neurological Events - Signs and Symptoms present
text
Neurological Events - Signs and Symptoms start date
date
Neurological Events - Signs and Symptoms end date
date
Neurological Events - Signs and Symptoms continuing at end of study
integer
Neurological Events - Signs and Symptoms - Seizures
Neurological Events - Specify seizures
integer
Neurological Events - Number of seizure episodes
integer
Neurological Events - Duration of longest seizure episode
text
Neurological Events - Signs and Symptoms
Neurological Events - Signs and Symptoms
integer
Specify Hyperreflexia
text
Specify Bowel dysfunction
text
Specify Pain in limbs
text
Specify Myelitis Transverse, lesion level
text
Neurological Events - Signs and symptoms present
text
Neurological Events - Signs and symptoms start date
date
Neurological Events - Signs and symptoms end date
date
Neurological Events - Signs and symptoms continuing at end of study
integer
Neurological Events - Other signs and symptoms
Neurological Events - Other signs and symptoms
Neurological Events - Other signs and symptoms
text
Neurological Events - Other signs and symptoms start date
date
Neurological Events - Other signs and symptoms end date
date
Neurological Events - Other signs and symptoms continuing at end of study
integer
Neurological Events - Diagnostic Test Results
Neurological Events - Test
integer
Neurological Events - Test done
text
Neurological Events - Test date
date
Neurological Events - Test Result
float
Neurological Events - Test Units
text
Neurological Events - Low Norm
float
Neurological Events - High Norm
float
Neurological Events - Other Diagnostic Test Results
Neurological Events - Other Diagnostic Test Results
Neurological Events - Test
text
Neurological Events - Test date
date
Neurological Events - Test Result
float
Neurological Events - Test Units
text
Neurological Events - Low Norm
float
Neurological Events - High Norm
float
Neurological Events - Other diagnostic Procedure
Describe any other diagnostic procedure supporting the diagnosis
text
Myasthenia Gravis
In case of serious adverse event
integer
In case of non-serious adverse event
integer
Date of final diagnosis:
date
Myasthenia Gravis - Signs and symptoms (supporting the final diagnosis)
Myasthenia Gravis - Signs and symptoms
integer
Myasthenia Gravis - Signs and symptoms present
text
Myasthenia Gravis - Signs and symptoms Start Date
date
Myasthenia Gravis - Signs and symptoms End date
date
Myasthenia Gravis - Signs and symptoms continuing at the end of study
text
Myasthenia Gravis - Other Signs and symptoms
Myasthenia Gravis - Other Signs and symptoms
Myasthenia Gravis - Other Signs and symptoms
text
Myasthenia Gravis - Other Signs and symptoms Start Date
date
Myasthenia Gravis - Other Signs and symptoms End Date
date
Myasthenia Gravis - Diagnostic Test Results
Myasthenia Gravis - Test
integer
Myasthenia Gravis - Test done
text
Myasthenia Gravis - Test date
date
Myasthenia Gravis - Test Result
float
Myasthenia Gravis - Test Units
text
Myasthenia Gravis - Low Norm
float
Myasthenia Gravis - High Norm
float
Myasthenia Gravis - Other Diagnostic Test Results
Myasthenia Gravis - Other Diagnostic Test Results
Myasthenia Gravis - Test
text
Myasthenia Gravis - Test date
date
Myasthenia Gravis - Test Result
float
Myasthenia Gravis - Test Units
text
Myasthenia Gravis - Low Norm
float
Myasthenia Gravis - High Norm
float
Myasthenia Gravis - Other diagnostic Procedure
Describe any other diagnostic procedure supporting the diagnosis
text
Uveitis
In case of serious adverse event
integer
In case of non-serious adverse event
text
Date of final diagnosis:
date
Uveitis - Signs and symptoms (supporting the final diagnosis)
Uveitis - Signs and symptoms
integer
Uveitis - Specify nervous findings
text
Uveitis - Specify ear/ nose / throat findings
text
Uveitis - Specify gastrointestinal disorders
text
Uveitis - Specify Pulmonary disorders
text
Uveitis - Specify genitourinary disoders
text
Uveitis - Specify dermatologic disoders
text
Uveitis - Specify musculoskeletal disoders
text
Uveitis - Signs and symptoms present
text
Uveitis - Signs and symptoms Start Date
date
Uveitis - Signs and symptoms End date
date
Uveitis - Signs and symptoms continuing at the end of study
integer
Uveitis - Other Signs and symptoms
Uveitis - Other Signs and symptoms
Uveitis - Other Signs and symptoms
text
Uveitis - Other Signs and symptoms Start Date
date
Uveitis - Other Signs and symptoms End Date
date
Uveitis - Diagnostic Test Results
Uveitis - Test
integer
Uveitis - Test done
text
Uveitis - Test date
date
Uveitis - Test Result
float
Uveitis - Test Units
text
Uveitis - Low Norm
float
Uveitis - High Norm
float
Uveitis - Other Diagnostic Test Results
Uveitis - Other Diagnostic Test Results
Uveitis - Test
text
Uveitis - Test date
date
Uveitis - Test Result
float
Uveitis - Test Units
text
Uveitis - Low Norm
float
Uveitis - High Norm
float
Uveitis - Other diagnostic Procedure