全英文病例报告表模板

更新时间:2023-07-02 10:45:16 阅读：评论：0

CASE REPORT FORM TEMPLATE

Version: 6.0 (8 November 2012)

PROTOCOL: [INSERT PROTOCOL NUMBER]

[INSERT PROTOCOL TITLE]

Participant Study Number:

Study group:

General Instructions for Completion of the Ca Report Forms (CRF)

Completion of CRFs

∙ A CRF must be completed for each study participant who is successfully enrolled (received at least one do of study drug)

∙ For reasons of confidentiality, the name and initials of the study participant should not appear on the CRF.

General

∙ Plea print all entries in BLOCK CAPITAL LETTERS using a black ballpoint pen.

∙ All text and explanatory comments should be brief.

∙ Answer every question explicitly; do not u ditto marks.

∙ Do not leave any question unanswered. If the answer to a question is unknown, write “NK” (Not Known). If a requested test has not been done, write “ND” (Not Done). If a question is not applicable, write “NA” (Not Applicable).

∙ Where a choice is requested, cross (X) the appropriate respon.

Dates and Times

∙ All date entries must appear in the format 05-May-2009. The month abbreviations are as follows:

January	=	Jan	May	=	May	September	=	Sep
February	=	Feb	June	=	Jun	October	=	Oct
March	=	Mar	July	=	Jul	November	=	Nov
April	=	Apr	August	=	Aug	December	=	Dec

In the abnce of a preci date for an event or therapy that precedes the participant’s inclusion into the study, a partial date may be recorded by recording “NK” in the fields that are where the day and month

are not clear, the following may be entered into the CRF:

N	K	N	K	2	0	0	美白肌肤的方法9
DD		MMM		YYYY
							腌臜

∙ All time entries must appear in 24-hour format e.g. 13:00. Entries reprenting midnight should be recorded as 00:00 with the date of the new day that is starting at that time.

Correction of Errors

∙ Do not overwrite erroneous entries, or u correction fluid or erars.

∙ Draw a straight line through the entire erroneous entry without obliterating it.

∙ Clearly enter the correct value next to the original (erroneous) entry.

女生齐肩发型

∙ Date and initial the correction.

PARTICIPANT INFORMATION

Participant Number

Study Group

______________________________________________

Study Site (Health Centre Name)

______________________________________________

Inclusion/exclusion criteria

*Patient must meet all criteria to eligible for the study

Met all 1.

Not met* 2.

Date of Informed Connt

D	D	M	M	M	Y	Y	Y	Y

Date of Birth

D	D	M	M	M	Y	Y	Y	Y

Or estimated age

_______

Gender

1 Male

2 Female

Pregnant

1. Yes

2. No

9. Unknown

If pregnant, Estimated Gestational Age ___________weeks

Date of Enrolment

D	D	M	M	M	Y	水黾科Y	Y	Y

Had malaria in the last 28 days

1. Yes

2. No

9. Unknown

Had antimalarial in the last 28 days

1. Yes

2. No

9. Unknown

chipmunk

BASELINE SYMPTOMS
Fever (in last 24 hours)	1. Yes	2. No	Duration: _______ days
Dizziness	1. Yes	2. No	Duration: _______ days
Headache	1. Yes	2. No	Duration: _______ days
Naua	1. Yes	2. No	Duration: _______ days
Anorexia	1. Yes	2. No	Duration: _______ days
Vomiting	1. Yes	2. No	Duration: _______ days
Diarrhoea	1. Yes	2. No	Duration: _______ days
Abdominal pain	1. Yes	2. No	Duration: _______ days
Itching	1. Yes	2. No	Duration: _______ days
Skin rash	1. Yes	2. No	Duration: _______ days
Urticaria	1. Yes	2. No	Duration: _______ days
Joint pain	1. Yes	2. No	Duration: _______ days
Muscle pain	1. Yes	2. No	Duration: _______ days
Palpitations	1. Yes	2. No	Duration: _______ days
Dyspnoea	1. Yes	2. No	Duration: _______ days
Hearing problem	1. Yes	2. No	Duration: _______ days
Confusion	1. Yes	2. No	Duration: _______ days
Visual blurring	1. Yes	2. No	Duration: _______ days
Fatigue	1. Yes	2. No	Duration: _______ days

Other symptom:	____________________	Duration: _______ days
Other symptom:	____________________	Duration: _______ days
Other symptom:	____________________	Duration: _______ days

bekeenon

MEDICATION HISTORY (within the last 7 days)

- Make multiple copies of this page if required

Medication Name

(write NK if unknown)

Start Date

Stop Date

______________________________

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	M	Y	Y	Y	Y

OR 1 Unknown

OR 1 Ongoing

______________________________

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	M	Y	Y	Y	Y

OR 1 Unknown

OR 1 Ongoing

______________________________

广州华章

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	M	Y	Y	Y	Y

OR 1 Unknown

OR 1 Ongoing

______________________________

街道办事处英文

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	M	Y	Y	Y	Y

OR 1 Unknown

OR 1 Ongoing

______________________________

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	外语角M	Y	Y	Y	Y

OR 1 Unknown

OR 1 Ongoing

______________________________

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	M	Y	Y	Y	Y

OR 1 Unknown

OR 1 Ongoing

______________________________

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	M	Y	Y	Y	Y
							高中英语作文范文

OR 1 Unknown

OR 1 Ongoing

______________________________

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	M	Y	Y	Y	Y

OR 1 Unknown

OR 1 Ongoing

______________________________

D	D	M	M	M	Y	Y	Y	Y

D	D	M	M	M	Y	Y	Y	Y

OR 1 Unknown

OR 1 Ongoing

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