Form CM - Concomitant Medications

CM - Concomitant Medications Header

Were any medications/therapies taken?

No  Yes

CM - Concomitant Medications       [No information given about how to repeat this Field Group]

What was the (concomitant) [medication/treatment/therapy] (name/term)?

For what indication was the (concomitant) [medication/treatment/therapy] taken?

What was the individual dose of the (concomitant) [medication/treatment/therapy]?

What is the unit (for the dose of concomitant [medication/treatment/therapy])?

Other, Specify

What was the dose form of the (concomitant) [medication/treatment/therapy]?

Other, Specify

What was the frequency of the (concomitant) [medication/treatment/therapy]?

Dose Frequency Other, Specify

What was the route of administration of the (concomitant) [medication/treatment/therapy]?

Other, Specify

What was the (concomitant) [medication/treatment/therapy/dose] start date?

Was the (concomitant) [medication/treatment/therapy] ongoing (as of [the study-specific time point or period])?

What was the (concomitant) [medication/treatment/therapy/dose] end date?

Choose Percent Volume per Volume Capsule Gram Inhalation International Dosing Unit Liter per Hour Liter per Minute Milligram Milligram per Kilogram Milliliter Milliliter per Hour Milliliter per Kilogram Puff Spray Tablet Microgram Microgram per Kilogram Other

Choose Aerosol Capsule Cream Gas Gel Inhalant Injectable Liquid Ointment Patch Powder Spray Suppository Suspension Tablet Other

Choose Twice Daily Once As Needed Daily Every Other Day Three Times Daily Unknown Other

Choose Intralesional Intramuscular Intraocular Intraperitoneal Nasal Oral Rectal Inhalation Subcutaneous Topical Transdermal Vaginal Other

01 Jan 2000

No  Yes

01 Jan 2000

* Mandatory field