Date Medical History Taken (M M/D D/Y Y Y Y): Does the participant/subject have a history of any medical problems/conditions in the following body systems? Yes No (leave rest of form blank) Enter all significant medical history items, including surgeries, EXCEPT the problem/condition that is the focus of this study. Use only one line per description. *Use BODY SYSTEM categories for medical history table: Constitutional symptoms (e.g., fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Table of medical history items subject’s/participant’s Medical History Start Date End Date Body System Term (one item Ongoing? (mm/dd/yyyy) (mm/dd/yyyy) per line) Data to be Data to be Data to be Data to be Yes entered by site entered by site entered by site entered by site No Data to be Data to be Data to be Data to be Yes entered by site entered by site entered by site entered by site No Data to be Data to be Data to be Data to be Yes entered by site entered by site entered by site entered by site No Data to be Data to be Data to be Data to be Yes entered by site entered by site entered by site entered by site No Data to be Data to be Data to be Data to be Yes entered by site entered by site entered by site entered by site No Data to be Data to be Data to be Data to be Yes entered by site entered by site entered by site entered by site No Data to be Data to be Data to be Data to be Yes entered by site entered by site entered by site entered by site No Data to be Data to be Data to be Data to be Yes entered by site entered by site entered by site entered by site No The following interview questions can be used to help make sure a complete medical history is documented.
Date Medical History Taken (M M/D D/Y Y Y Y): Does the participant/subject have a history of any medical problems/conditions in the following body systems? Yes No (leave rest of form blank) Enter all significant medical history items, including surgeries, EXCEPT the problem/condition that is the focus of this study. Use only one line per description. *Use BODY SYSTEM categories for medical history table: Constitutional symptoms (e.g., fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Table of subject’s/participant’s medical history items Body System Medical History Term (one item per line) Start Date (mm/dd/yyyy) Ongoing? End Date (mm/dd/yyyy) Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site The following interview questions can be used to help make sure a complete medical history is documented.
F1152_Medical_History.docx