SEARCH Medical Inventory

SEARCH for Diabetes in Youth Study

4a1_medication inventory registry

SEARCH Medical Inventory

OMB: 0920-0904

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Have you taken in last 2 days?

‰ Rosiglitazone (Avandia) ....................

‰ Repaglinide (Prandin) .......................

‰ Pioglitazone (Actos)..........................

‰ Glyburide (Micronase, Diabeta,
Glynase) .........................................

‰ Glipizide (Glucotrol) ……………………….

‰ Glimepiride (Amaryl) ……………………..

‰ Acarbose (Precose, Prandase) ………..

‰ Metformin (Glucophage) …………………

‰ Yes

‰ Yes

‰ Yes

‰ Yes

‰ Yes

‰ Yes

‰ Yes

‰ Yes

‰ Yes

‰ No

‰ No

‰ No

‰ No

‰ No

‰ No

‰ No

‰ No

‰ No

‰ No

(Check yes or no)

‰ Rosglitazone/Metformin (Avandamet)

‰ Yes

Oral Medications for diabetes

‰ Nateglinide (Starlix) .........................

2

1

‰ Yes

‰ Yes

‰ Yes

‰ No

‰ No

‰ No

‰ No

Have you taken in last 2
days? (Check yes or no)

3

‰ Yes

‰ No

Other Medications (including diabetes medications not listed above)

4

‰ Yes

Page 2 of 3

5

SEARCH 3 Registry Study - Medications Inventory Form – 11-01-10

(Continue to next page)

9

8

7

6

‰ Yes

‰ Yes

‰ Yes

‰ Yes

‰ Yes

‰ No

‰ No

‰ No

‰ No

‰ No

Data Entry
Code

Reviewer Code

Completed by

FOR STUDY USE ONLY

Year

Year

Day

Year

Day

Month

Day

Month

Month

Page 3 of 3

10

Date
Completed
Date
Reviewed
Date
Entered

SEARCH 3 Registry Study - Medications Inventory Form – 11-01-10


File Typeapplication/pdf
File TitleMicrosoft Word - Registry Medicatons Inventory revised_03-08-07_11-01-10 FINAL FINAL
Authorstmoxley
File Modified2011-05-10
File Created2010-10-29

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