Visit Date
Vital Signs
If Yes, complete below
boolean
Date of assessment
date
Check one box only
integer
Systolic BP
integer
Diastolic BP
integer
Heart Rate
integer
Respiration Rate
integer
Temperature
float
Check one box only
integer
Weight
float
Check one box only
integer
Hematology
If No, or if results are not available, please complete details on the comments page or the protocol deviations page.
boolean
Date and time of sample
datetime
(if different from main hospital laboratory)
text
Hematology
Parameter
integer
Result
text
Units
text
Check one box only. If any result is clinically significant, please record a diagnosis on the adverse event page.
integer
Not Done
integer
Clinical Chemistry, Coagulation and Electrolytes
If No, or if results are not available, please complete details on the comments page or the protocol deviations page.
boolean
Date and time of sample
datetime
(if different from main hospital laboratory)
text
Clinical Chemistry, Coagulation and Electrolytes
Parameter
integer
Results
text
Units
text
Check one box only. If any result is clinically significant, please record a diagnosis on the adverse event page.
integer
Not Done
integer
Urinalysis dipstick results
If No, or if results are not available, please complete details on the comments page or the protocol deviations page.
boolean
Date of sample
date
Time of sample
time
(if different from main hospital laboratory)
text
pH
integer
If other pH, please specify
text
Glucose
integer
If other Glucose, please specify
text
Blood
integer
If other Blood, please specify
text
Protein
integer
If other Protein, please specify.
text
Leucocytes
integer
If other Leucocytes, please specify.
text
Urinalysis microscopy results
Check one box only. If No, or if results are not available, please complete details on the comments page or the protocol deviations page.
integer
Date of sample
date
Time of sample
time
If different from main hospital laboratory
text
Urinalysis microscopy results
Parameter
integer
Result
text
Units
text
Not Done
integer
Clinically significant?
boolean
Bortezomib Administration
Was bortezomib administered at this visit?
boolean
Date administered
date
Lot #
integer
Time Administered
time
Dose Level
integer
BSA
integer
Dose Admin
integer