12-month 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 the 6-month post-procedure visit (CRF #22)

Yes

THIS FORM SHOULD REFLECT ANY CHANGES IN MEDICATIONS SINCE THE 6-MONTH POST-PROCEDURE VISIT.

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