eCRF XForms example
Courtesy of
XML4Pharma
Form: Baseline
Subject ID :
Subject ID
Study Event ID:
Group: Common
Site number:
Must be an integer.Value must be lower than 100
Visit Date:
Must be a valid date. Correct format is: yyyy-mm-dd
Group: Demographics
Date of Birth:
Must be a valid date. Correct format is: yyyy-mm-dd
Sex:
Male
M
Female
F
Race:
Caucasian
CAUCASIAN
Black
BLACK
Asian
ASIAN
Other
OTHER
Group: Smoking History
Is the subject a smoker?
Number of cigarettes per day:
Less Than 10 cigarettes per day
LT10
10 to 20 cigarettes per day
10TO20
Greater Than 20 cigarettes per day
GT20
Group: Drinking history
Number of alcoholic drinks per day:
Less Than 1 drink per day
LT1
1 to 2 drinks per day
1TO2
Greater Than 2 drinks per day
GT2
Group: Physical examination: Baseline
Height (cm):
The height value should be below 220 cm
Weight (kg):
The weight value should be below 150 kg
Systolic BP (mm Hg):
The value should be below 180
Diastolic BP (mm Hg):
The value should be below 120
Does the subject feel dizzy when standing up from a sitting position?
No
0
Yes
1
Group: Complaints related to smoking
Breathing:
No
0
Yes
1
Coughing:
No
0
Yes
1
Heart:
No
0
Yes
1
No. of illness days last year:
Must be an integer.Value must be lower than 1000
Number of bronchitis cases during the last year:
Must be an integer.Value must be lower than 100
Number of pneumonia cases last year:
Must be an integer.Value must be lower than 100
Submit Data
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