ID

10258

Descrizione

ADVL0212- Review Form (Dr. Chin) FR901228 in Treating Children With Refractory or Recurrent Solid Tumors or Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C0F2E959-BAAB-54D8-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C0F2E959-BAAB-54D8-E034-0003BA12F5E7

Keywords

  1. 26/08/12 26/08/12 -
  2. 22/05/15 22/05/15 -
  3. 03/06/15 03/06/15 - Julian Varghese
Caricato su

22 maggio 2015

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0 Legacy

Commenti del modello :

Puoi commentare il modello dati qui. Tramite i fumetti nei gruppi di articoli e articoli è possibile aggiungere commenti a quelli in modo specifico.

Commenti del gruppo di articoli per :

Commenti dell'articolo per :

Per scaricare i modelli di dati devi essere registrato. Per favore accesso o registrati GRATIS.

ADVL0212- Review Form (Dr. Chin)

No Instruction available.

  1. StudyEvent: ADVL0212- Review Form (Dr. Chin)
    1. No Instruction available.
ECG Assessment
Descrizione

ECG Assessment

Date of ECG
Descrizione

Date of ECG

Tipo di dati

date

Did patient experience any of the following: SVT, atrial fibrillation, or atrial flutter?
Descrizione

Didpatientexperienceanyofthefollowing:SVT,atrialfibrillation,oratrialflutter?

Tipo di dati

text

check all that apply
Descrizione

checkallthatapply

Tipo di dati

text

Did patient experience prolonged QTc compared to baseline?
Descrizione

DidpatientexperienceprolongedQTccomparedtobaseline?

Tipo di dati

text

check all that apply
Descrizione

checkallthatapply

Tipo di dati

text

Was there a T wave inversion in leads II, III, AVF (inferior leads) or V4, V5, and V6 (lateral leads)?
Descrizione

WasthereaTwaveinversioninleadsII,III,AVF(inferiorleads)orV4,V5,andV6(lateralleads)?

Tipo di dati

text

Was ST segment at the J-point greater than or equal to 2 mm below baseline in leads II, II AVF (inferior leads), V4, V5, V6 (lateral leads)?
Descrizione

WasSTsegmentattheJ-pointgreaterthanorequalto2mmbelowbaselineinleadsII,IIAVF(inferiorleads),V4,V5,V6(lateralleads)?

Tipo di dati

text

Did patient experience ventricular arrhythmia?
Descrizione

Didpatientexperienceventriculararrhythmia?

Tipo di dati

text

Ccrr Module For Advl0212- Review Form (dr. Chin)
Descrizione

Ccrr Module For Advl0212- Review Form (dr. Chin)

Similar models

No Instruction available.

  1. StudyEvent: ADVL0212- Review Form (Dr. Chin)
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
ECG Assessment
DateofECG
Item
Date of ECG
date
Item
Did patient experience any of the following: SVT, atrial fibrillation, or atrial flutter?
text
Code List
Did patient experience any of the following: SVT, atrial fibrillation, or atrial flutter?
CL Item
Yes (Yes)
CL Item
No (No)
Item
check all that apply
text
Code List
check all that apply
CL Item
SVT (SVT)
CL Item
Atrial fibrillation (Atrial fibrillation)
CL Item
Atrial flutter (Atrial flutter)
Item
Did patient experience prolonged QTc compared to baseline?
text
Code List
Did patient experience prolonged QTc compared to baseline?
CL Item
Yes (Yes)
CL Item
No (No)
Item
check all that apply
text
Code List
check all that apply
CL Item
To greater than or equal to 480 msec (To greater than or equal to 480 msec)
CL Item
Increase of greater than or equal to 50 msec (Increase of greater than or equal to 50 msec)
CL Item
Increase by 15 % (Increase by 15 %)
Item
Was there a T wave inversion in leads II, III, AVF (inferior leads) or V4, V5, and V6 (lateral leads)?
text
Code List
Was there a T wave inversion in leads II, III, AVF (inferior leads) or V4, V5, and V6 (lateral leads)?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Was ST segment at the J-point greater than or equal to 2 mm below baseline in leads II, II AVF (inferior leads), V4, V5, V6 (lateral leads)?
text
Code List
Was ST segment at the J-point greater than or equal to 2 mm below baseline in leads II, II AVF (inferior leads), V4, V5, V6 (lateral leads)?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Did patient experience ventricular arrhythmia?
text
Code List
Did patient experience ventricular arrhythmia?
CL Item
Yes, change in VT (Yes, change in VT)
CL Item
Yes, change in VF (Yes, change in VF)
CL Item
Yes, change in both VT and VF (Yes, change in both VT and VF)
CL Item
No (No)
Item Group
Ccrr Module For Advl0212- Review Form (dr. Chin)

Si prega di utilizzare questo modulo per feedback, domande e suggerimenti per miglioramenti.

I campi contrassegnati da * sono obbligatori.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial