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<label>ECG</label><br/>
|
|
|
<label>28 Cycle 1 Dosing Day 1</label>
|
|
|
<br/><br/>
|
|
|
<label>Rate: </label><input type="text" name="txt_rate" /> <label>Intervals: </label>
|
|
|
<input type="checkbox" name="chk_opt1" />PR
|
|
|
<input type="checkbox" name="chk_opt2" />QRS
|
|
|
<input type="checkbox" name="chk_opt3" />QT
|
|
|
<input type="checkbox" name="chk_opt4" />QTc
|
|
|
<br/><br/>
|
|
|
<label>Machine Interpretation: </label><br/>
|
|
|
<textarea cols="50" rows="5"></textarea>
|
|
|
<br/>
|
|
|
<label>Does the Investigator agree or disagree with this interpretation?</label><br/>
|
|
|
<input type="radio" name="rbn_opt" />Agree
|
|
|
<input type="radio" name="rbn_opt" />Disagree
|
|
|
<br/><br/>
|
|
|
<label>*If disagrees, alternative interpretation must be provided below:</label><br/>
|
|
|
<textarea cols="50" rows="5"></textarea>
|
|
|
<br/>
|
|
|
<label>Were findings clinically significant?</label><br/>
|
|
|
<input type="radio" name="rbn_opt" />Yes**
|
|
|
<input type="radio" name="rbn_opt" />No
|
|
|
<br/><label>**Report on AE page.</label>
|
|
|
<br/><br/>
|
|
|
<table border="1">
|
|
|
<thead>
|
|
|
<tr>
|
|
|
<th>Date<br/>DD/MM/YYYY</th>
|
|
|
<th>Interval<br/>Hoour</th>
|
|
|
<th>Select<br/>Appropiate</th>
|
|
|
<th>Target</th>
|
|
|
<th>Actual Time</th>
|
|
|
</tr>
|
|
|
</thead>
|
|
|
<tbody>
|
|
|
<tr>
|
|
|
<td><input type="text" name="txt_date1" /></td>
|
|
|
<td>Immediately<br/>(Pre-Dose)</td>
|
|
|
<td><input type="text" name="txt_dateRep" value="" /></td>
|
|
|
<td><input type="text" name="txt_dateRep" value="" /></td>
|
|
|
<td><input type="text" name="txt_dateRep" /></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td></td>
|
|
|
<td>End of<br/>Infusion(hr. 4)</td>
|
|
|
<td><input type="text" name="txt_dateRep" value="" /></td>
|
|
|
<td><input type="text" name="txt_date1" /></td>
|
|
|
<td><input type="text" name="txt_dateRep" /></td>
|
|
|
</tr>
|
|
|
</tbody>
|
|
|
</table>
|
