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Example Case Report Forms for MH domain


Form: General Medical History

Question Response
Medical History Verbatim
Approximate start date of condition
Outcome of the condition

Approximate date of recovery from the condition
Severity of the condition



Form: Diabetes History

Question Response
Collection Date
Date of Diagnosis of Diabetes?
Type of Diabetes


Form: Diabetes Complications

Question Response
Collection Date
Diabetic Retinopathy

Neuropathy

Nephropathy

Peripheral Vascular Disease

Diabetic Ketoacidosis

Date of Diagnosis

Form: General Medical History

Question Response
Collection Date
Medical History Verbatim
Start Date
End Date
Ongoing


Form: Anemia History

Question Response
Medical Condition
Date of diagnosis
Did the patient have any symptoms of Anemia in

Shortness of breath
Fatigue
Other symptoms
If 'Other', specify

Form: Chronic Kidney Diseaase History

Question Response
Medical Condition
Date of diagnosis
Stage of Chronic Kidney Disease


What is the likely etiology of CKD?