Prior Crohn's Disease Medication: Immunomodulators

This CRF collects information about individual immunomodulator medications previously used to treat Crohn's disease.

This is a repeating CRF that is completed once for each immunomodulator medication previously used to treat Crohn's disease.

"Prior Crohn's Disease Medication Class- Immunomodulators [CD_CMIM]" Form Preview

Prior Crohn's Disease Medication Class- Immunomodulators

Prior Crohn's Disease Medication Class- Immunomodulators 1

* What is the category for the medication?

* For what indication was the medication taken?

* What is the subcategory for the medication?

* What was the medication identifier?

* What was the name of the immunomodulator drug taken for Crohn's disease?

What was the start date of this immunomodulator?

01 Jan 2000

What was the end date of this immunomodulator?

01 Jan 2000

How many months did the subject take this immunomodulator?

* What was the maximum dose amount of this immunomodulator?

* What was the unit of the maximum dose amount of this immunomodulator?

* What was the frequency of the maximum dose amount of this immunomodulator?

* What was the final dose amount of this immunomodulator?

* What was the final dose amount unit of this immunomodulator?

* What was the frequency of the final dose amount of this immunomodulator?

* What was the route of administration of this immunomodulator?

* What was the primary reason for discontinuation of this immunomodulator?

If "Non-response", was the subject receiving a treatment regimen for this immunomodulator which, according to protocol-defined criteria, was expected to be efficacious?

No Yes

If "Non-response", what were the signs and symptoms leading to discontinuation of treatment?

If "Other", specify.

Prior Crohn's Disease Medication Class- Immunomodulators 2

* What was the category of the medical history?

* When did the medical history event start relative to the study reference period?

* What was the relationship to the non-study medication?

* If treatment was discontinued due to intolerance, what was the condition indicating intolerance?

If "Other", what was the other condition indicating intolerance to previous immunomodulator treatment?

* Mandatory field

Package(s)
CD CMIM Package