Download Yes ¨No ¨Unknown

CORE CASE RECORD FORM for Severe Acute Respiratory Infection – 23/04/2013
Please complete sections 1-4 at admission. Complete sections 5-10 after discharge/death. Additional information can be recorded
on the SUPPLEMENTARY DATA FORM. Daily information can be recorded on the DAILY RECORD FORM
1. Demographics
This page completed: At admission During hospital stay After discharge
Patient identification code: ___ ___ - ___ ___ ___
Date of birth (DD/MM/YYYY): ___ /___ /____ OR Estimated age _______ years
Clinical centre:____________________________ Country: _________________ Form completed by:_______________________
First name initial: ____ Surname initial: ____
Sex: Male Female
Ethnicity: ____________ _____________Unknown
Weight (at admission): ______kg/lbs (circle) Height: _______cm/inches (circle)
MUAC (if age<5yrs)________cm/inches (circle)
Transferred from another facility? Yes No Unknown
Admission date at this facility (DD/MM/YYYY): ___ /___/20___
If YES: Date admitted to other facility (DD/MM/YYYY):__ /__ /20____ Name of transferring facility:________________________
Suspected/confirmed infection: H7N9 Novel coronavirus H5N1 Other:_______________________________
History of close contact with a case of infection above? Yes, confirmed case Yes, suspected case No
Has the patient travelled within 10 days of symptom onset?
Yes No Unknown
Unknown
If YES, state location(s) below:
Country:_________________________ City: __________________________ Return Date (DD/MM/YYYY): ____ /____ /20______
Country:_________________________ City: __________________________ Return Date (DD/MM/YYYY): ____ /____ /20______
In the previous 10 days, did the patient have contact with live animals? Yes No Unknown
If YES, specify Animal ______________________ Type of contact:_________________________________________________
2. Co-morbidities & Risk Factors (existing PRIOR TO ADMISSION & that are active problems)
Congestive heart failure
Dementia
Chronic pulmonary disease
(not asthma)
Physician diagnosed asthma
Rheumatologic disease
Mild liver disease
Moderate or severe liver disease
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes
Yes
Yes
Yes
No
No
No
No
Unknown
Unknown
Unknown
Unknown
(Charlson Index will be calculated at analysis)
Diabetes with chronic complications
Hemiplegia or paraplegia
Renal disease
Any malignancy including leukaemia
& lymphoma
Metastatic solid tumour
AIDS / HIV
Obese as defined by clinical staff
History of recurrent fever prior to admission? Yes No Unknown
Yes
Yes
Yes
Yes
No
No
No
No
Unknown
Unknown
Unknown
Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Proven Malaria? Yes No Unknown
Receiving immunosuppressants (including inhaled/oral corticosteroids) prior to admission? Yes No Unknown If YES:
Name of immunosuppressant
Dose and frequency
unknown
Pregnant? Yes No Unknown NA
Post-partum? Yes No NA
Route of administration
Duration
IV
oral
inhaled
other unknown
days weeks
unknown
Gestation at admission: ________weeks (round to nearest)
Delivery date (DD/MM/YYYY) __ /___/20__
Outcome: Live birth Still birth
Baby tested for infection above? Yes No Unknown If YES: Positive Negative Method: PCR Other: _________
Infants (<1 year old): birth weight if known: ______kg/lbs (circle)  Term-born (≥37wk GA) Preterm(<37wk GA) Unknown
Breastfed? Yes No Unknown
If YES: Still breastfeeding Discontinued (at _______ weeks)
Development appropriate for age? Yes No Unknown Vaccinations appropriate for age & country? Yes No Unknown
Any other risk factor(s) considered relevant:
1
CORE CASE RECORD FORM for Severe Acute Respiratory Infection – 23/04/2013
3. Signs and Symptoms at Admission (please complete every line)
Date of onset of earliest symptom (DD/MM/YYYY):
/
/20
OR if unknown, day-of-illness at admission:
days
Temperature:_________°C/°F (circle)
HR: _______beats per minute
RR:________ breaths per minute
Systolic BP:_______mmHg Diastolic BP: _______mmHg
Sternal capillary refill time >2secs? Yes No Unknown
Intubated & ventilated? Yes No Unknown
If intubated & ventilated: FiO2 ________ Unknown
Not ventilated but receiving O2? Yes No Unknown
O2 saturation: _____%
On room air? Yes No Unknown
Severe dehydration? Yes No Unknown
Urine output: Oliguria (<1mL/kg/hr infants, <0.5mL/kg/hr children and adults ) Anuria (no urine output)  Unknown
Admission signs and symptoms (associated with this episode of acute illness)
History of fever (>38°C)
Yes No Unknown
Lower chest wall indrawing
Yes No Unknown
Cough
Yes No Unknown
Headache
Yes No Unknown
with sputum production
Yes No Unknown
Altered consciousness/confusion
Yes No Unknown
bloody sputum/haemoptysis
Yes No Unknown
Seizures
Yes No Unknown
Sore throat
Yes No Unknown
Abdominal pain
Yes No Unknown
Runny nose (rhinorrhoea)
Yes No Unknown
Vomiting/nausea
Yes No Unknown
Ear ache
Yes No Unknown
Diarrhoea
Yes No Unknown
Wheezing
Yes No Unknown
Conjunctivitis
Yes No Unknown
Chest pain
Yes No Unknown
Skin rash
Yes No Unknown
Muscle aches (myalgia)
Yes No Unknown
Skin ulcers
Yes No Unknown
Joint pain (arthralgia)
Yes No Unknown
Lymphadenopathy
Yes No Unknown
Fatigue/malaise
Yes No Unknown
Bleeding
Yes No Unknown
Shortness of breath
Yes No Unknown
Biochemistry & Haematology
4. Admission Laboratory Results
If bleeding, specify site:
_____________________
Please circle the unit used for each parameter, where appropriate. Enter “NM” if not measured.
No results available
Date laboratory samples collected (DD/MM/YYYY): ____ /____ /20_____
Haemoglobin ______ g/L, g/dL
Haematocrit ____________%
WBC count ____________ x 109/L, x103/μL
Platelets __________ x 109/L, x103/μL
APTT/APRT (circle)__________
PT/INR________________ seconds
ALT/SGPT _________ U/L
Bilirubin _______μmol/L, mg/dL
C-reactive protein ________ mg/L, nmol/L
AST/SGOT _________ U/L
Glucose _______mmol/L, mg/dL
Erythrocyte Sed Rate ______mm/h
Blood Urea Nitrogen _____ mmol/L, mg/dL LDH __________ U/L
Creatinine _________ μmol/L, mg/dL
Creatine kinase (CPK) ______U/L
Lactate _______ mmol/L, mg/dL
Blood Gas
Date blood gas performed (DD/MM/YYYY): ____ /____ /20_____ Blood gas not performed
Sample taken on:  Room air Supplemental O2 Unknown
If receiving O2, specify: _________% or ________l/min
Sample type:  Arterial  Venous  Capillary Unknown
PO2
kPa, mmHg
pH
PCO2
kPa, mmHg
Base excess
mmol/L
HCO3-
mEq/L
Lactate
mmol/L, mg/dL
Any other significant laboratory results:
Patient identification code: ___ ___ - ___ ___ ___
Date of birth (DD/MM/YYYY): ___ /___ /____
2
CORE CASE RECORD FORM for Severe Acute Respiratory Infection – 23/04/2013
5. Complications: At any time during hospitalisation did the patient experience (please complete every line):
Viral pneumonitis
Yes No Unknown
Cardiac arrest
Yes No Unknown
Bacterial pneumonia
Yes No Unknown
Bacteraemia
Yes No Unknown
Acute lung injury / ARDS
Yes No Unknown
Coagulopathy or DIC
Yes No Unknown
Pneumothorax
Yes No Unknown
Anaemia
Yes No Unknown
Pleural effusion
Yes No Unknown
Rhabdomyolysis or myositis
Yes No Unknown
Bronchiolitis
Yes No Unknown
Acute renal injury/failure
Yes No Unknown
Meningitis/Encephalitis
Yes No Unknown
Gastrointestinal bleeding
Yes No Unknown
Seizure(s)
Yes No Unknown
Pancreatitis
Yes No Unknown
Stroke
Yes No Unknown
Hepatic dysfunction
Yes No Unknown
Congestive heart failure
Yes No Unknown
Hyperglycemia
Yes No Unknown
Endo/myo/peri-carditis
Yes No Unknown
Hypoglycemia
Yes No Unknown
Cardiac arrhythmia
Yes No Unknown
Other
Yes No Unknown
Cardiac ischaemia
Yes No Unknown
If Other, specify:
6. Treatment: At any time during hospitalisation, did the patient receive (please complete every line)
If Daily Treatment was recorded on a DAILY RECORD FORM (Section 2), leave this section blank and check here 
Care on ICU/ITU/IMC/HDU? Yes No Unknown
If YES, state the Date of admission to ICU/ITU/IMC/HDU (DD/MM/YYYY): ____ /____ /20____
Date Unknown
If YES, state the Total number of days in ICU/ITU/IMC/HDU during this hospital stay: _______days Days Unknown
Supplemental oxygen? Yes No Unknown …………………………………………………………….... If YES, duration: _________ days
Non-invasive mechanical ventilation? (eg. BIPAP, CPAP) Yes No Unknown…………… If YES, duration: _________ days
Invasive mechanical ventilation? Yes No Unknown ……………………….…………………… If YES, duration: _________ days
Oscillatory Ventilation? Yes No Unknown ………………………..…………………………………... If YES, duration: _________ days
Extracorporeal membrane oxygenation (ECMO) or interventional lung-assist therapy (iLA)?
ECMO iLA None Unknown Not available……………………........................... If YES, duration: ________ days
Renal replacement therapy (RRT) or dialysis? Yes No Unknown........................... If YES, duration: _________ days
RRT required beyond discharge from hospital? Yes No Unknown
Plasmapheresis? Yes No Unknown
Inotropes/vasopressors?
Yes No Unknown
Oral rehydration only? Yes No Unknown
Intravenous Immunoglobulin?
Yes No Unknown
Blood transfusion or products? Yes No Unknown
OTHER intervention (please specify):
Patient identification code: ___ ___ - ___ ___ ___
Date of birth (DD/MM/YYYY): ___ /___ /____
3
CORE CASE RECORD FORM for Severe Acute Respiratory Infection – 23/04/2013
7. Pathogen Testing
Only record results that are not recorded on a DAILY RECORD FORM (Section 4).
Was pathogen testing performed? Yes No Unknown If YES, complete each line below.
Date (DD/MM/YYYY)
____ /____ /20____
____ /____ /20____
____ /____ /20____
____ /____ /20____
____ /____ /20____
____ /____ /20____
____ /____ /20____
____ /____ /20____
____ /____ /20____
____ /____ /20____
____ /____ /20____
Sample Type
Pathogen
Result
Method
Nasal/NP swab
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
Throat swab
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
Combined nasal/NP +
Throat swab
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
Sputum
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
BAL
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
ETA
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
Stool/Rectal swab
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
Urine
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
Blood
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
Other (specify):
__________________
Specify:
_______________________
Positive
Negative
Unknown
PCR other:
_______________
Serology
Specify:
_______________________
Antibody Titre:
________________________________________
8. Other Infections: Did the patient test positive for any other infection? Yes No Unknown If YES, specify.
(DD/MM/YYYY)
Sample Type
(choose from list in #7 above)
Type of Infection
Pathogen
____ /____ /20____
Specify:
___________________________
 Bacterial  Viral  Fungal
 Other:_________________
Specify:
_____________________________
____ /____ /20____
Specify:
___________________________
 Bacterial  Viral  Fungal
 Other:_________________
Specify:
_____________________________
____ /____ /20____
Specify:
___________________________
 Bacterial  Viral  Fungal
 Other:_________________
Specify:
_____________________________
____ /____ /20____
Specify:
___________________________
 Bacterial  Viral  Fungal
 Other:_________________
Specify:
_____________________________
Date of Detection
9. Medication: While hospitalised or at discharge, were any of the following administered?
Yes No Unknown
Antibiotics? Yes No Unknown
Corticosteroids? Yes No Unknown
Antifungals? Yes No Unknown
Antivirals?
Angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs)? Yes No Unknown
Statins? Yes No Unknown If YES, was the patient taking statins prior to admission? Yes No Unknown
Patient identification code: ___ ___ - ___ ___ ___
Date of birth (DD/MM/YYYY): ___ /___ /____
4
CORE CASE RECORD FORM for Severe Acute Respiratory Infection – 23/04/2013
Medication: List ONLY ANTI-INFECTIVES and CORTICOSTEROIDS administered in hospital or at discharge.
Name of medication
Start date
End date
Route of administration
Dose and frequency
(generic name preferred)
(DD/MM/YYYY)
(DD/MM/YYYY)
____ /____ /________
On-going
____ /____ /20______
IV
oral inhaled
other unknown
____ /____ /________
On-going
____ /____ /20______
____ /____ /________
On-going
____ /____ /20______
____ /____ /________
On-going
____ /____ /20______
____ /____ /________
On-going
____ /____ /20______
____ /____ /________
On-going
____ /____ /20______
____ /____ /________
On-going
____ /____ /20______
IV
other
IV
other
IV
other
IV
other
IV
other
IV
other
oral inhaled
unknown
oral inhaled
unknown
oral inhaled
unknown
oral inhaled
unknown
oral inhaled
unknown
oral inhaled
unknown
unknown
unknown
unknown
unknown
unknown
unknown
unknown
10. Outcome: Date outcome section completed (DD/MM/YYYY): ____ /____ /20______
Resolution of acute illness? Yes No Unknown If YES, date of resolution (DD/MM/YYYY): ____ /____ /20____ Unknown
Still in hospital? Yes No Unknown
Transferred to another facility? Yes No Unknown
If transferred, date of transfer (DD/MM/YYYY): ____ /____ /20______ Name of new facility: _________________Unknown
Discharged? Yes No Unknown
If YES, state the date of discharge (DD/MM/YYYY): ____ /____ /20______
Ability to self-care at discharge versus prior to illness: Same as prior to illness Decreased Increased Unknown
Respiratory support/treatment? Yes No Unknown
Post-discharge treatment (if alive, check all that apply):
Renal Treatment? Yes No Unknown
Other Treatment? Yes No Unknown
If YES, specify:
Specify other treatment (multiple permitted):
Diagnoses at discharge:
1.
2.
3.
4.
5.
Died in hospital or palliative discharge? Yes No Unknown
If YES, date of death (DD/MM/YYYY): ____ /____ /20______
Was an autopsy performed?
Cause(s) of death:
Yes No Unknown
Key autopsy results:
Patient identification code: ___ ___ - ___ ___ ___
Date of birth (DD/MM/YYYY): ___ /___ /____
5
DAILY RECORD FORM for Severe Acute Respiratory Infection – 23/04/2013
Please complete daily during hospital admission. Any additional information can be added on paper to the SUPPLEMENTARY DATA
FORM, Section 7–Any other additional information or directly to the electronic CRF on the CliRes database, Section 11-Additional
Information.
1. Date and Demographics
Date (DD/MM/YYYY): ____/____/20____
Study Day: [____][____][____] or 3 months 6 months
Patient identification code: ___ ___ - ___ ___ ___
Date of birth (DD/MM/YYYY): ___ /___ /____ OR Estimated age ____
2. Daily Treatment: (please complete every line daily during admission):
Is the patient currently receiving, or has s/he received in the past 24 hours (since the last report from was completed):
Care on ICU/ITU/IMC/HDU? Yes No Unknown
Supplemental oxygen? Yes No Unknown
Non-invasive mechanical ventilation? (eg. BIPAP, CPAP) Yes No Unknown
Invasive mechanical ventilation? Yes No Unknown
Oscillatory Ventilation? Yes No Unknown
Extracorporeal membrane oxygenation (ECMO) or interventional lung-assist therapy (iLA)? ECMO iLA None Unknown
Renal replacement therapy (RRT) or dialysis? Yes No Unknown
Plasmapheresis? Yes No Unknown
Inotropes/vasopressors? Yes No Unknown
Oral rehydration only? Yes No Unknown
Intravenous Immunoglobulin? Yes No Unknown
Blood transfusion or products? Yes No Unknown
OTHER intervention (please specify):
3. Daily Laboratory Results – for samples collected on the date listed above
Biochemistry & Haematology
Please circle the unit used for each parameter, where appropriate. Enter “NM” if not measured.
No results available
Haemoglobin ______ g/L, g/dL
Haematocrit ____________%
WBC count ____________ x 109/L, x103/μL
Platelets __________ x 109/L, x103/μL
APTT/APRT (circle)__________
PT/INR________________ seconds
ALT/SGPT _________ U/L
Bilirubin _______μmol/L, mg/dL
C-reactive protein ________ mg/L, nmol/L
AST/SGOT _________ U/L
Glucose _______mmol/L, mg/dL
Erythrocyte Sed Rate ______mm/h
Blood Urea Nitrogen _____ mmol/L, mg/dL LDH __________ U/L
Creatinine _________ μmol/L, mg/dL
Creatine kinase (CPK) ______U/L
Lactate _______ mmol/L, mg/dL
Blood Gas
Blood gas not performed
Sample taken on:  Room air Supplemental O2 Unknown
If receiving O2, specify: _________% or ________l/min
Sample type:  Arterial  Venous  Capillary Unknown
PO2
kPa, mmHg
pH
PCO2
kPa, mmHg
Base excess
Any other significant laboratory results:
mmol/L
HCO3-
mEq/L
Lactate
mmol/L, mg/dL
DAILY RECORD FORM for Severe Acute Respiratory Infection – 23/04/2013
4. Pathogen Testing
Was pathogen testing performed on the date above? Yes No Unknown If YES, complete each line that applies.
Sample Type
Pathogen
Result
Method
Nasal/NP swab
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
Throat swab
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
Combined nasal/NP + throat
swab
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
Sputum
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
BAL
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
ETA
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
Stool/Rectal swab
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
Urine
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
Blood
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
Other (specify):
_______________________
Specify:
_______________________
Positive
Negative
Unknown
PCR
other: ______________
Serology
Specify:
_______________________
Antibody Titre:
_______________________________________________
Patient identification code: ___ ___ - ___ ___ ___
Date of birth (DD/MM/YYYY): ___ /___ /____
DAILY RECORD FORM for Severe Acute Respiratory Infection – 23/04/2013
[TIER3C]
5. Pharmacokinetics (PK) of Antimicrobials / Immunomodulatory Drugs
Drug under study:
Start date of drug prescription:
Prescribed times of
administration:
Specify: _______________________
Date (DD/MM/YYYY) ____ /____ /20____
Specify All: ___________________________________________________________
*Precise* time of 1st PK blood
draw today:
Time (24 hour clock H H : M M) ___ ___ : ___ ___
*Precise* time of 2nd PK blood
draw today:
Time (24 hour clock H H : M M) ___ ___ : ___ ___
*Precise* time of 3rd PK blood
draw today:
Time (24 hour clock H H : M M) ___ ___ : ___ ___
Please record all doses of the drug given in the last 24hrs:
Dose:
Amount: ________
Units:_________
Amount: ________
Units:_________
Amount: ________
Units:_________
Amount: ________
Units:_________
Amount: ________
Units:_________
Amount: ________
Units:_________
Route of administration
IV
oral
oral
oral
oral
oral
oral
___ ___ : ___ ___
___ ___ : ___ ___
___ ___ : ___ ___
___ ___ : ___ ___
___ ___ : ___ ___
___ ___ : ___ ___
___ ___ : ___ ___
___ ___ : ___ ___
inhaled
other:_______________
Patient identification code: ___ ___ - ___ ___ ___
___ ___ : ___ ___
inhaled
other:_______________
IV
___ ___ : ___ ___
inhaled
other:_______________
IV
___ ___ : ___ ___
inhaled
other:_______________
IV
___ ___ : ___ ___
inhaled
other:_______________
IV
*Precise* End Time
(infusion only)
(24 hour clock HH:MM)
inhaled
other:_______________
IV
*Precise* Time Drug Given
(if infusion: Start Time)
(24 hour clock HH:MM)
Date of birth (DD/MM/YYYY): ___ /___ /____
SUPPLEMENTARY DATA FORM for Severe Acute Respiratory Infection – 23/04/2013
Use this form to record information that does not fit the space provided in the CASE REPORT FORM. All information from the CASE REPORT
FORM and SUPPLEMENTARY DATA FORM should be entered into the appropriate sections of the electronic CASE REPORT FORM.
1. Case Tracking Information
Demographics should match those entered in the CRF
Patient identification code: ___ ___ - ___ ___ ___
Date of birth (DD/MM/YYYY): ___ /___ /____ OR Estimated age ____
First name initial: ____ Surname initial: ____
2. Has the patient travelled within 10 days of symptom onset – Additional Travel Locations
This refers to Section 1-Demographics of the CRF. If more than two locations were visited, enter the details of additional
locations below:
Country:________________________ City: __________________________ Return Date (DD/MM/YYYY): ____ /____ /20______
Country:________________________ City: __________________________ Return Date (DD/MM/YYYY): ____ /____ /20______
Country:________________________ City: __________________________ Return Date (DD/MM/YYYY): ____ /____ /20______
3. In the previous 10 days, did the patient have contact with live animals – Additional Animal Contacts
This refers to Section 1-Demographics of the CRF. If there was more than one animal contact, enter the details of additional
contacts below:
Animal ______________________ Type of contact:
Animal ______________________ Type of contact:
Animal ______________________ Type of contact:
Animal ______________________ Type of contact:
4. Receiving immunosuppressants prior to admission – Additional Immunosuppressants
This refers to Section 2-Co-morbidities & Risk Factors of the CRF. If more than one immunosuppressant was being taken by the
patient prior to admission, please enter the details of additional immunosuppresants below:
Name of immunosuppressant
Dose and frequency
unknown
unknown
unknown
unknown
unknown
Route of administration
IV
oral inhaled
other unknown
IV
oral inhaled
other unknown
IV
oral inhaled
other unknown
IV
oral inhaled
other unknown
IV
oral inhaled
other unknown
Duration
days weeks
unknown
days weeks
unknown
days weeks
unknown
days weeks
unknown
days weeks
unknown
SUPPLEMENTARY DATA FORM for Severe Acute Respiratory Infection – 23/04/2013
5. Other Infections: Did the patient test positive for any other infection? – Additional infections
This refers to Section 8-Other Infections of the CRF. If the patient was positive for more than one of any type of infection, please
enter the details of additional infections below:
Date of Detection
(DD/MM/YYYY)
____ /____ /20____
Sample Type
(choose from list in Core CRF #7)
Specify:
___________________________
____ /____ /20____
Specify:
___________________________
____ /____ /20____
Specify:
___________________________
____ /____ /20____
Specify:
___________________________
Type of Infection
Bacterial Viral Fungal
Other:________________
Bacterial Viral Fungal
Other:________________
Bacterial Viral Fungal
Other:________________
Bacterial Viral Fungal
Other:________________
Pathogen
Specify:
___________________________
Specify:
___________________________
Specify:
___________________________
Specify:
___________________________
6. Anti-infective and corticosteroid medications received during hospitalisation or at discharge – Additional Medications
This refers to Section 9-Medication of the CRF. If further space is required to list additional anti-infective or corticosteroid
medications, please enter them below:
List ONLY ANTI-INFECTIVES and CORTICOSTEROIDS administered in hospital or at discharge.
Name of medication
Start date
End date
Route of administration
(DD/MM/YYYY)
(DD/MM/YYYY)
(generic name
preferred)
On-going IV
oral inhaled
____ /____ /________ ____ /____ /20______
other unknown
On-going IV
oral inhaled
____ /____ /________ ____ /____ /20______
other unknown
On-going IV
oral inhaled
____ /____ /________ ____ /____ /20______
other unknown
On-going IV
oral inhaled
____ /____ /________ ____ /____ /20______
other unknown
On-going IV
oral inhaled
____ /____ /________ ____ /____ /20______
other unknown
On-going IV
oral inhaled
____ /____ /________ ____ /____ /20______
other unknown
On-going IV
oral inhaled
____ /____ /________ ____ /____ /20______
other unknown
On-going IV
oral inhaled
____
/____
/20______
____ /____ /________
other unknown
7. Any other additional information
Dose and
frequency
unknown
unknown
unknown
unknown
unknown
unknown
unknown
Enter any other relevant information not captured in the CRF
This information can be entered into Section 11-Additional Information of the electronic CRF on the CliRes database.
Patient identification code: ___ ___ - ___ ___ ___
unknown
Date of birth (DD/MM/YYYY): ___ /___ /____