Patient Pre-Screening Log

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Patient Pre-Screening Log
Site:
Principal Investigator:
EudraCT No:
2011-000719-19
ISRCT No: 15948785
MREC trial Number: 11/SW/0036
Complete post
Eligibility for Screening
PLEASE OBSCURE BEFORE FAXING
registration
Eligible for
Allergies to
Previous
Taking
Screening
Consent
Recruiting
trial drug
Patient
or
Previous
Wish to
part in
for entry
given for
Patient Hospital
Clinic (Please
Date patient
Taking
constituents
Identifying
Initials
Date of Birth
current
or current
conceive
another
screening
into
Number
entered onto log
Age
delete as
Amiodarone
gelatine,
number
Reason ineligible/consent not given
(FML)
(DD/MM/YY)
thyroid
cardiac
in next 12
placebo
(if no,
TABLET?
(DD/MM/YY)
appropriate)
or Lithium?
magnesium
disease
disease?
months?
controlled
specify
Screening
sterate or
reason)
history?
IMP trial?
(give PIS to
lactose
patient)
**
Miscarriage/
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N/ NK
___/___/___ ___/___/___
Infertility
Miscarriage/
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N/ NK
___/___/___ ___/___/___
Infertility
Miscarriage/
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N/ NK
___/___/___ ___/___/___
Infertility
Miscarriage/
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N/ NK
Infertility
___/___/___ ___/___/___
Miscarriage/
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N/ NK
Infertility
___/___/___ ___/___/___
Miscarriage/
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N/ NK
Infertility
___/___/___ ___/___/___
Miscarriage/
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N/ NK
Infertility
___/___/___ ___/___/___
Miscarriage/
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N/ NK
Infertility
___/___/___ ___/___/___
Of:
Page:
TABLET Trial Office, FREEPOST RRKR‐JUZR‐HZHG, Birmingham Clinical Trials Unit, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TT
Tel: 0121 415 9111; Fax: 0121 415 9136; Email: tablet‐trial@contacts.bham.ac.uk; Website:
TABLET Pre-Screening log
Ver. 5.0 29/11/12
Please note, this version is for printing and handwritten completion ONLY.

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