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Pharmaceutical industry / Drug rehabilitation / Research / Amines / Eli Lilly and Company / Methadone / Adverse event / Case report form / Medicine / Chemistry / Clinical research


Document Date: 2012-06-06 06:50:59

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File Size: 2,00 MB

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Company

NCR / /

Event

Product Recall / Product Issues / /

Facility

Laboratory Evaluations Has / LABORATORY DATA Protocol Centre Number Patient Number Patient Initials Laboratory Data / LABORATORY EVALUATION Has / /

IndustryTerm

investigational site / /

MedicalCondition

allergy / scabies / inter-current illness / present illness / convulsions / cancer / severe malaria / On-going Example Aspirin Headache / concomitant infection / probable uncomplicated clinical malaria / /

MedicalTreatment

elective surgery / /

MusicGroup

Nausea / /

Organization

Centre Number Patient Number Patient Initials Visit / Centre Number Patient Number Patient Initials Extra Visit xxxxx / Centre Number Patient Number Patient Initials Serious Adverse Experiences xxxx / Outpatient Department / /

Position

Investigator / Physician / complete and accurate Investigator / /

Product

Concomitant Medications xxxxx/xx INSTRUCTIONS FOR COMPLETING THE CONCOMITANT MEDICATION / due Yes No Please / CHECKLIST PROMPT FOR ADVERSE EVENTS CONCOMITANT MEDICATIONS ADMINISTER STUDY MEDICATION / Condition Medication / mefloquine / PCR HAEMATOLOGY DATA BIOCHEMISTRY DATA PRIOR MEDICATION / CONCOMITANT MEDICATION / Physical Examination Study Medication Record Concomitant Medication / Case Report Form CONCOMITANT MEDICATION / No Yes Randomisation/Study Medication / dapsone / Fansidar / Case Report Form STUDY MEDICATION / /

Technology

Confidential Case Record Form Protocol Title Protocol / 3 Protocol / Case Report Form PARASITOLOGY Protocol / u/l Sample date LABORATORY DATA Protocol / 2 Suspected Protocol / u/l Sample date Protocol / 2 Protocol / 25 p.m. Protocol / /

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