PERI-PROCEDURAL CONCOMITANT MEDICATIONS

Site

Patient Number

Please enter in three digit format (e.g., 001, 002, ..., 025)

Is this an original or revised submission?

Original

Revised

Name of the Person Entering Data into this CRF

First Name

Last Name

Have there been any changes in medications since Visit #1 and the completion of CRF #6?

Yes

Did the patient receive any medication to address the post-procedural symptoms after UFE?

Yes

THIS FORM SHOULD REFLECT THE MEDICATIONS USED DURING THE RECOVERY PERIOD AFTER UFE AND ANY CHANGES SINCE VISIT #1 (AND THE COMPLETION OF CRF #6)

Medication #1 (Name of Medication, Dose, and Indication)

Medication #2 (Name of Medication, Dose, and Indication)

Medication #3 (Name of Medication, Dose, and Indication)

Medication #4 (Name of Medication, Dose, and Indication)

Medication #5 (Name of Medication, Dose, and Indication)

Medication #6 (Name of Medication, Dose, and Indication)

Medication #7 (Name of Medication, Dose, and Indication)

Medication #8 (Name of Medication, Dose, and Indication)

Medication #9 (Name of Medication, Dose, and Indication)

Medication #10 (Name of Medication, Dose, and Indication)

Additional Medications

Attestation

I approve the data entered into this CRF and attest to its accuracy.

Date of Completion

YYYY