Example Case Report Forms for MH domain
Sources: DB1 | Forms loaded: 6
Form: General Medical History
Show domain info
Primary Domain
MH
All Domains
MH
# Question Response
1
Medical History Verbatim
field_001
2
Approximate start date of condition
field_002
3
Outcome of the condition
field_003
4
Approximate date of recovery from the condition
field_004
5
Severity of the condition
field_005
Example Case Report Forms for MH domain
Sources: DB1 | Forms loaded: 6
Form: Diabetes History
Show domain info
Primary Domain
MH
All Domains
MH
# Question Response
1
Collection Date
mh801_1.MHDAT
2
Date of Diagnosis of Diabetes?
mh801_1.MHSTDAT
3
Type of Diabetes
mh801_1.MHTERM
4
field_004
Example Case Report Forms for MH domain
Sources: DB1 | Forms loaded: 6
Form: Diabetes Complications
Show domain info
Primary Domain
MH
All Domains
MH
# Question Response
1
Collection Date
mh801_1.MHDAT
2
Diabetic Retinopathy
mh801_2.MHTERM</br>_mh801_2.MHOCCUR
3
Neuropathy
mh801_2.MHTERM</br>_mh801_2.MHOCCUR_2
4
Nephropathy
mh801_2.MHTERM</br>_mh801_2.MHOCCUR_3
5
Peripheral Vascular Disease
mh801_2.MHTERM</br>_mh801_2.MHOCCUR_4
6
Diabetic Ketoacidosis
mh801_2.MHTERM</br>_mh801_2.MHOCCUR_5
7
Date of Diagnosis
mh801_2.MHSTDAT
8
field_008
Example Case Report Forms for MH domain
Sources: DB1 | Forms loaded: 6
Form: General Medical History
Show domain info
Primary Domain
MH
All Domains
MH
# Question Response
1
Collection Date
mh801_3.MHDAT
2
Medical History Verbatim
mh801_3.MHTERM
3
Start Date
mh801_3.MHSTDAT
4
End Date
mh801_3.MHENDAT
5
Ongoing
mh801_3.MHONGO
6
field_006
Example Case Report Forms for MH domain
Sources: DB1 | Forms loaded: 6
Form: Anemia History
Show domain info
Primary Domain
MH
All Domains
MH
# Question Response
1
Medical Condition
field_001
2
Date of diagnosis
field_002
3
Did the patient have any symptoms of Anemia in
field_003
4
Shortness of breath
field_004
5
Fatigue
field_005
6
Other symptoms
field_006
7
If 'Other', specify
field_007
8
field_008
Example Case Report Forms for MH domain
Sources: DB1 | Forms loaded: 6
Form: Chronic Kidney Diseaase History
Show domain info
Primary Domain
FA
All Domains
FA, MH
# Question Response
1
Medical Condition
field_001
2
Date of diagnosis
field_002
3
Stage of Chronic Kidney Disease
field_003
4
What is the likely etiology of CKD?
field_004
5
field_005