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? | |