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Example Case Report Forms for CM domain


Form: Anti-hyperglycemic agents

Question Response
Collection Date
Did the subject take any anti-hyperglycemic agent in the last 10 years?

If yes, List the Treatments received
Treatment Name
Start Date
Ongoing?

End Date
Dose
Dose Unit




Frequency






Route










Form: General Concomitant Medications

Question Response
Treatment Name
Taken prior to the study?

Indication
Start Date
Ongoing?

End Date
Dose
Dose Unit




Frequency






Route










Form: Concomitant Medications

Question Response
Medication category
Medication
Taken prior to study?

Date First Taken
Date Last Taken
Indication
Dose
Unit
Frequency
Route