Download:
pdf |
pdf 6. Have you taken any other diabetes medications in the last 8 hours?
1
Yes (if YES, ask which medications were taken and mark by the appropriate list of
2
No
medications below; then answer question 6a at the bottom of the page)
Other diabetes medications:
1
Acarbose
Actos
Avandament
Avandia
Glucophage
Glyset
Metformin
Miglitol
Precose
Pioglitazone
Rosiglitazone
Acceptable medications
Amaryl
Byetta
2
1
Chlorpropamide
DiaBeta
Diabinese
Exenatide
Glimepiride
Glipizide
Glucotrol
Glucovance
Glyburide
Glynase
Januvia
Liraglutide
Micronase
Nateglinide
Prandin
Pramlintide
Repaglinide
Sitagliptin
Starlix
Symlin
Tolazamide
Tolbutamide
Victoza
Time:
Hour
Minute
AM
PM
NOT acceptable if taken within 8 hours prior to
fasting blood sample
Proceed with blood draw and try to re-schedule
a fasting re-draw visit.
Other diabetes medications: (specify)
IF UNACCEPTABLE INSULIN OR ORAL MEDICATION TAKEN, PROCEED WITH BLOOD DRAW AND TRY TO
SCHEDULE A FASTING RE-DRAW VISIT.
6a.
If a re-draw visit is necessary, has Patient agreed? 1
SEARCH 3 Registry and Cohort Studies - Specimen Collection form 11-01-10
Yes
2
No
Page 2
7. Have you had anything to eat or drink in the last 8 hours?
1
Yes
7a. if YES, ask the Patient what they had
to eat or drink. Describe what they had to
eat or drink.
7b. if Patient consumed non-allowable food
AM PM
Time:
or drink, record most recent time
Hour
Minute
IF FASTING LESS THAN 8 HOURS, PROCEED WITH BLOOD DRAW AND TRY TO
SCHEDULE A FASTING RE-DRAW VISIT.
7c.
2
If a re-draw visit is necessary, has Patient agreed? 1 Yes
2
No
No
8. Glucose meter reading:
(May use drop from blood collected with venipuncture samples)
If glucose is > 300 mg/dl, perform urinary ketone check and record.
8a. Urine ketones:
1
Negative
2
3
Trace/small
Moderate
4
9. Were any of the following symptoms observed or reported by the Patient?
Large
1
5
Yes
(If YES, check all that apply):
1
Abdominal pain
1
Diaphoresis (excessive sweating)
1
Lightheadedness
1
Nausea and or vomiting
1
Seizure
1
Tremors or trembling
1
Loss of consciousness due to low blood glucose
1
Loss of consciousness due to phlebotomy (fainting)
1
Blood glucose is < 45 mg./dl.
1
Blood glucose is > 300 mg./dl. with moderate or large ketones
1
Blood glucose is > 500 mg./dl. with or without ketones
1
Other (specify):
Unable to obtain
2No
10. Comments?
1
2
Yes (if YES, describe) :
No comments
NOTE: Complete SEARCH Unanticipated Occurrence/Condition Reporting Form if
any of the below presents:
•
•
seizure
loss of consciousness due to low blood glucose
SEARCH 3 Registry and Cohort Studies - Specimen Collection form 11-01-10
Page 3
11. Specimen obtained
by:
(code)
12. Date specimen
obtained:
Month
Day
13. Time specimen
Year
AM / PM (check one)
collected:
Hour
Minute
Please instruct the Patient to take medication/insulin and provide a breakfast to the Patient.
FOR STUDY USE ONLY
Date Completed
Completed by
Month
Day
Year
Date Reviewed
Reviewer Code
Month
Day
Year
Date Entered
Month
Day
Year
SEARCH 3 Registry and Cohort Studies - Specimen Collection form 11-01-10
Data Entry
Code
Page 4
| File Type | application/pdf |
| File Title | Microsoft Word - Specimen Collection - Reg and Cohort - 11-01-10 FINAL FINAL FINAL _minor revision 10-29_ |
| Author | stmoxley |
| File Modified | 2011-05-10 |
| File Created | 2010-11-03 |