| Question | Response |
|---|---|
| Treatment Name | |
| Taken prior to the study? | Yes No |
| Indication | |
| Start Date | |
| Ongoing? | Yes No |
| End Date | |
| Dose | |
| Dose Unit | mg ug mL g IU |
| Frequency | BID TID QID QOD QM PRN UNKNOWN |
| Route | ORAL TOPICAL SUBCUTANEOUS TRANSDERMAL INTRAOCULAR INTRAMUSCULAR RESPIRATORY (INHALATION) INTRAPERITONIAL NASAL RECTAL |