ࡱ> W bjbj,, FaFaFj  @PD8aP (!!! * * *&a(a(a(a(a(a(a$QcfLa  *))"*|@+@La  !!aa222+ ! !&a2 *&a22VDY!GVB4>,L,W"awa0aNWf,fDDYDYfBY0 * *2 * * * * *LaLa"/j * * *a * * * *f * * * * * * * * * B : HEADER: PI NAME, Protocol or IRB Number, Protocol Short Title  Subject Initials Subject ID Date: / /  Month Day Year  Medical History (General) Body SystemDiagnosed condition?Diagnosis/Condition/SurgeryOnset Date Or YearCurrent Problem[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No[insert body system being inquired about] FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  NoOther (specify) FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No ADDITIONAL NOTES:  FORMCHECKBOX  Medical History Not Obtained MEDICAL HISTORY OBTAINED BY:     Form Number: Version Date: 10/20/2016 Page  PAGE 1 of  NUMPAGES 1  Optional Investigator Identifier (CDASH Domain: Common) CDASH/SDTM Variable Name: INVID  Highly Recommended Protocol/Study Identifier (CDASH Domain: Common) CDASH/SDTM Variable Name: STUDYID  Highly Recommended Site No (If Applicable) (CDASH Domain: Common) CDASH/SDTM Variable Name: SITEID  Highly Recommended Subject Identifier (CDASH Domain: Common) CDASH/SDM Variable Name: SUBJID  Optional Med History Date (CDASH Domain: MH) CDASH Variable Name: MHDAT SDTM Variable Name: MHDTC (ISO 8601 format) This date format is not CDASH recommended. The CDASH-recommended date format is 2 numerical digits for the day, 3 digits for the month, 4 numerical digits for the year (e.g., 08-AUG-2008).  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