Fillable Prior and Concomitant Medications (National Institutes of Health)

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Prior and Concomitant Medications (National Institutes of Health)

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Prior and Concomitant Medications
STUDY NAME
Site Number:
Pt_ID:
_____________________
_____________________
Were any concomitant medications taken by the participant __ days before or during the study? Yes (If so record below) No
5.
Medication Indication Start Date
(dd/mmm/yyyy)
Stop Date
(dd/mmm/yyyy)
Ongoing
1.
2.
3.
4.
Prior and Concomitant Medication Page ___ of ____ Version 1.0
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Prior and Concomitant Medications (National Institutes of Health)

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Completed 19 July 2020

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