Medical History (a) STUDY NAME Site Number: / / . Pt_ID: d d m m m y y y y Visit Date: Visit Type: Screening Baseline Does the participant have a medical or surgical history, current or resolved, of any of the following? Current / MEDICAL HISTORY Yes / No Unknown If Yes, Explain Resolved Yes Current Head, Eye, Ear, Nose, Throat No Resolved Yes Current Respiratory No Resolved Yes Current Cardiovascular No Resolved Yes Current Gastrointestinal No Resolved Yes Current Genitourinary No Resolved Yes Current Musculoskeletal No Resolved Yes Current Neurological No Resolved Yes Current No Resolved Yes Current Blood/Lymphatic No Resolved Yes Current Dermatologic No Resolved Yes Current Psychiatric No Resolved Yes Current Allergy No Resolved Other, specify: Yes Current No Resolved
Medical History (a) STUDY NAME Site Number: Pt_ID: Visit Date: / / . d d m m m y y y y Visit Type: Screening Baseline Does the participant have a medical or surgical history, current or resolved, of any of the following? MEDICAL HISTORY Yes / No Unknown If Yes, Explain Current / Resolved Head, Eye, Ear, Nose, Throat Yes No Current Resolved Respiratory Yes No Current Resolved Cardiovascular Yes No Current Resolved Gastrointestinal Yes No Current Resolved Genitourinary Yes No Current Resolved Musculoskeletal Yes No Current Resolved Neurological Yes No Current Resolved Yes No Current Resolved Blood/Lymphatic Yes No Current Resolved Dermatologic Yes No Current Resolved Psychiatric Yes No Current Resolved Allergy Yes No Current Resolved Other, specify: Yes No Current Resolved
4a_Medical_History_Conventional_ver1_07-17-2015.docx