Medical and Surgical History

SUBJECT ID ______________
SynAct-CS002 SUBJECT INITIALS ______________

Medical and Surgical History

Is there any
Start Date End Date
Is the condition related
Seq Description of Medical MM/DD/YYYY MM/DD/YYYY
Ongoing Severity related to study concomitant Date/Initials
No.: Diagnosis/Surgical Procedure (Please provide as (Please provide as
indication? treatment still
minimum the year) minimum the year)
ongoing?
 Mild
 No  Moderate  No  No
 Yes  Severe  Yes  Yes*
 NA
 Mild
 No  Moderate  No  No
 Yes  Severe  Yes  Yes*
 NA
 Mild
 No  Moderate  No  No
 Yes  Severe  Yes  Yes*
 NA
 Mild
 No  Moderate  No  No
 Yes  Severe  Yes  Yes*
 NA
 Mild
 No  Moderate  No  No
 Yes  Severe  Yes  Yes*
 NA
 Mild
 No  Moderate  No  No
 Yes  Severe  Yes  Yes*
 NA
* Please complete Con.med. page

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