CDEs
Forms
Working Diagnosis 1 Status (circle one)
Check this box if patient was primarily diagnosed with an infection or disease that was acquired or existed at home prior to departure or which was acquired after travel but prior to the clinic visit.
Drinking ever PhenX
Drinking weekly PhenX
Drinking Ys PhenX
Age range lifetime alcohol exp PhenX
Drinks per D, W, Mo, Y PhenX
Do you have hemophilia?
Cancer chemotherapy received in the past 4W or will be received in the next 4W
Exclusion Criteria
Blood draw done PhenX
Blood draw sample PhenX
Make of equipment used PhenX
Manufacturer name
Father pregnancy ever PhenX
Father pregnancy times PhenX
Father pregnancy age PhenX
Planned pregnancy PhenX
How many months did it take for your partner to achieve pregnancy [PhenX]
Multiple pregnancy PhenX
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