Fillable Visit Checklist - Sample (National Institutes of Health)

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Visit Checklist - Sample (National Institutes of Health)

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The Visit Checklist - Sample (National Institutes of Health) form is 1 page long and contains:

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  • 11 check-boxes
  • 5 other fields

Country of origin: US
File type: PDF

U.S.A. forms for National Institutes of Health

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Visit Checklist - Sample
Visit Checklist Version 1.0
STUDY NAME
Site Number:
Pt_ID:
___________________
___________________
Visit Date:
__ __ / __ __ __ / 2 0_ __ __
d d m m m y y y y
1. Did the participant attend this visit? Yes (If yes, continue) No
2. Please check all assessments completed at this visit:
Visit Name: Baseline
Demographics
Medical History
Vital Signs
Physical Exam
Prior and Concomitant Medication
Inclusion/Exclusion Criteria
Randomization and Enrollment
3. Is the participant continuing in the study? Yes No
If no, remember to complete a STUDY COMPLETION form.
If yes, schedule next visit.
Comments:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Completed 19 July 2020

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