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T-
PLAQUE
Patient Sheet
STANDALONE
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Patient Information
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Adverse Event Log
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Concomitant Medications
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IP Dispensing Log
VISITS
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Screening / Baseline
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ICF Date & Time
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Demographics
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Childbearing Potential
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Cigarette Smoking
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Medical History
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Surgical History
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Risk Factors
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Eligibility Criteria
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Physical Examination
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Vital Signs
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Lab Data
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ECG
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CCTA
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Comments
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Randomization Visit
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Visit 2 / Month 1
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Visit 3 / Month 3
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Phone Visit 1
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Visit 4 / Month 6
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Phone Visit 2
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Visit 5 / Month 9
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Phone Visit 3
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Visit 6 / Month 12
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Phone Visit 4 (End of Study)
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Patient Information
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Subject Initials
Screening # (patient number)
T-PLAQUE-
Randomization #
Gender
M
F
Preferred Language
English
Spanish
Full name
Birthdate
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MRN #
SSN #
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Address
Address (line 2)
Phone Number
Work Number
Home Number
Cell Number
Email
Alternate Contact
Relationship
Alternate Contact's Phone Number
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