You are viewing an old version of this page. View the current version.

Compare with Current View Page History

« Previous Version 8 Next »

This is an example Medical History CRF. This CRF collects verbatim descriptions of any medical conditions or events experienced by the subject. 



OrderQuestion TextPromptCase Report Form Completion InstructionsTypeCollection VariableTabulation Target  Mapping Instructions  Controlled Terminology CodeList NamePermissible ValuesPre-Populated Value
1Has the subject had any medical conditions or events?Any Medical HistoryIndicate if the subject experienced any medical conditions or events. If Yes, include the appropriate details where indicated on the CRF.MHYNN/A
(NY)Yes; No

2
Medical History Category
MHCATMHCAT


GENERAL MEDICAL HISTORY
3What is the medical condition or event identifier?MH NumberApplicant-Defined CRF Completion InstructionsMHSPIDMHSPID




4What is the medical condition or event term?Medical History TermRecord all relevant medical conditions or events, as defined in the protocol. Record only one medical condition or event per line. Ensure that the medical conditions or events listed on the Medical History page do not meet any of the exclusion criteria.MHTERMMHTERM




5What was the medical condition or event start date?Start DateRecord the start date of the medical event or condition using this format (DD-MON-YYYY).MHSTDATMHSTDTC




6Is the medical condition or event ongoing?OngoingRecord the medical condition or event as ongoing (Yes) if it has not ended at the time of data collection; the end date should be left blank.MHONGOMHENRF/  MHENRTPT
(NY)Yes; No

7What was the medical condition or event end date?End DateRecord the end date of the medical event or condition using this format (DD-MON-YYYY).MHENDATMHENDTC




  • No labels