User's Manual
Case Form Report
A
-5
Trial ID : Version No. : 1.0 : 30/07/2007
Screening
Subject No.: Subject Initials : Center No.:
Date of visit :
D M
M
Y Y Y Y
Exclusion Criteria
Yes No N/A
1. Do you have a gastrointestinal disorder (suspected
malignantlesions or gastrointestinal obstructive disorders,
perforation, stenosis or fistula)?
2. Do you have a cardiovascular disorder (dysrhythemia, trouble
with cardiac conduction system, hypertension(high blood
pressure) or ischemic heart disease)?
3. Have you been diagnosed of cardiac insufficiency, angina
pectoris or cardiac arrest (heart attack) in recent 6 months?
4. Are you with (or implanted) medical devices such as cardiac
pacemaker or defibrillator?
5. Do you have a swallowing disorder?
6. Do you have delayed gastric emptying or serious gastric
disorder?
7. Are you a pregnant or nursing woman, or a woman of child
bearing potential?
8. Are you an infant or epileptic? Are you easily affected by
electronic waves?
9. Do you have several small bowel diverticulums ?
10. Did you fail to obtain a voluntary agreement?
11. Are you judged unqualified for this test by doctors or nurses?
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CONFIDENTIAL