Physical Examination
Pregnancy Test
If applicable: Was pregnancy test performed?
boolean
Date of Collection
date
Accession Number
text
Pregnancy Test
boolean
Biochemistry/Proteomics
Reason Off Treatment
Death
Did the patient die before the Post-treatment visit? (If Yes, complete section below as well as Adverse Events page and Serious Adverse Event Report Form)
boolean
Primary Cause of Death
integer
Cause of death
text
Autopsy
integer
Investigator Signature
I have reviewed the data recorded in this Case Report Form. To the best of my knowledge, it is a complete and accurate representation of the patient's status during the study.
text
Investigator Signature Date
date