The Case Report Form Template UK is offered in multiple formats including PDF, Word, and Google Docs, featuring editable and printable samples for your convenience.
Case Report Form Template UK Editable – PrintableSample
Case Report Form Template UK 1. Patient Information 2. Consultant Information 3. Case Identification 4. Diagnosis and Medical History 5. Presenting Symptoms 6. Examination Findings 7. Investigations Conducted 8. Treatment Administered 9. Follow-Up Plans and Recommendations 10. Consent Information 11. Declaration of Accuracy
PDF
WORD
Examples
Study Title: [Title of the Study]
Study ID: [Unique Study Identifier]
Study Version: [Version Number]
Date of Form Completion: [Date]
Participant ID: [Unique Participant Identifier]
Gender: [Gender]
Age: [Age]
Date of Birth: [YYYY-MM-DD]
Address: [Participant Address]
Description of Adverse Event: [Detailed Description]
Date of Onset: [Date]
Severity: [Mild/Moderate/Severe]
Resulting Action: [Action Taken]
Product Name: [Name of the Product]
Dosage: [Dosage]
Route of Administration: [e.g., Oral, Intravenous]
Start Date: [Start Date]
End Date: [End Date]
Medication Name: [Name of Medication]
Dosage: [Dosage]
Indication: [Reason for Administration]
Outcome Measure: [Measure Taken]
Date of Assessment: [Date]
Result: [Positive/Negative/Indeterminate]
[Investigator Name]
Date: [Signature Date]
[Investigator Signature]
Participant ID: [Unique Participant Identifier]
Date of Enrollment: [Enrollment Date]
Consent Obtained: [Yes/No]
Ethnicity: [Ethnicity]
Height: [Height]
Weight: [Weight]
Relevant Past Medical History: [Medical Conditions]
Current Medications: [List of Medications]
Examination Date: [Examination Date]
Vital Signs: [Blood Pressure, Heart Rate, etc.]
Physical Examination Findings: [Findings]
Test Name: [Name of Test]
Test Date: [Test Date]
Result: [Result of Test]
Next Follow-up Date: [Date]
Follow-up Actions Required: [Actions Required]
[Investigator Name]
Date: [Signature Date]
[Investigator Signature]
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