SEARCH Medical Inventory (Registry Study)

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

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

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9

8

7

6

! Yes

! Yes

! Yes

! Yes

! No

! No

! No

! No

Data Entry
Code

Reviewer Code

Completed by

FOR STUDY USE ONLY

Year

Year

Year

! No

Day

Day

Day

! Yes

Month

Month

Month

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Date
Completed
Date
Reviewed
Date
Entered

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