baseline 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

1) Is the patient on any medications?

Yes

IF THE ANSWER TO #1 IS "YES", PLEASE SPECIFY THE MEDICATIONS BELOW. IF THE ANSWER TO #1 IS "NO", THEN PLEASE COMPLETE THE ATTESTATION BELOW.

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

Text

Please specify if "other" is selected above.