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<label>Prior and Concomitant Medications</label><br/><br/>
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<label>Are there any medications to be recorded on this page?</label>
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<input type="radio" name="rbn_opt"/>Yes <input type="radio" name="rbn_opt"/>No<br/>
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<label>(Including prescription, over-the-counter, herbal and vitamin products)</label><br/><br/>
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<table border="0" class="tbl_general">
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<thead>
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<tr>
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<th>Medication<br/>(generic name preferred)</th>
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<th>Dose</th>
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<th>Units<br/>(eg, mg,<br/>IU, mL)</th>
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<th>Route,<br/>(eg, PO,<br/>SC)</th>
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<th>Frequency<br>(eg, QD, BID,<br>TID, QID)</th>
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<th>Date Started<br>DD/MMM/YYYY</th>
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<th>Ongoing?*</th>
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<th>Date Stopped<br>DD/MMM/YYYY</th>
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<th>Use to Treat AE?<br/>Yes | No** | AE#s</th>
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<th>**If No, List Indication</th>
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</tr>
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</thead>
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<tbody>
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<tr>
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<td><input type="text" name="txt_medicat" value="" /></td>
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<td><input type="text" name="txt_dose" value="" style="width: 20px" /></td>
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<td>
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<select name="lst_units" class="form_select">
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<option value="1">eg</option>
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<option value="1">mg</option>
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<option value="1">IU</option>
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<option value="1">mL</option>
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</select>
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</td>
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<td><input type="text" name="txt_route" value="" /></td>
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<td><input type="text" name="txt_frequency" value="" /></td>
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<td><input type="text" name="txt_dtStart" value="" /></td>
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<td><input type="text" name="txt_ongoing" value="" /></td>
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<td><input type="text" name="txt_dtStop" value="" /></td>
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<td><input type="text" name="txt_opt" value="" /></td>
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<td><input type="text" name="txt_indication" value="" /></td>
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</tr>
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</tbody>
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<tfoot>
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<tr><td colspan="10"><Small>*If medication is continuing at the end of the study, place a check in the Outgoing column and skip date.</Small></td></tr>
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</tfoot>
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</table>
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<br/><br/>
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