ID
13030
Beschrijving
Placebo controlled,double blind and randomized parallel group trial to verify effectivity and tolerability of moxaverine p.o. in patients with central nervous vertigo. Sponsor: URSAPHARM Industriestrasse 66129 Saarbrücken Phone 06805-9292-0 Fax 06805- 929288 Head of clinical trial: Univ.-Prof.Dr.med. Ralph Mösges Medical Faculty, University of Cologne Phone 0221-4783456 Fax 0221-4783465
Trefwoorden
Versies (1)
- 12-01-16 12-01-16 -
Geüploaded op
12 januari 2016
DOI
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Licentie
Creative Commons BY-NC 3.0
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Moxaverine 200mg p.o. in patients with central nervous vertigo Visit 4
Case report form Visit 4
- StudyEvent: ODM
Beschrijving
otorhinolaryngologic examination
Beschrijving
Otoscopy
Datatype
text
Alias
- UMLS CUI [1]
- C0419361
Beschrijving
Otoscopy
Datatype
text
Alias
- UMLS CUI [1]
- C0419361
Beschrijving
Rinne test
Datatype
text
Alias
- UMLS CUI [1]
- C0278245
Beschrijving
Rinne test
Datatype
text
Alias
- UMLS CUI [1]
- C0278245
Beschrijving
Webers test
Datatype
text
Alias
- UMLS CUI [1]
- C0278247
Beschrijving
Webers test
Datatype
text
Alias
- UMLS CUI [1]
- C0278247
Beschrijving
Nystagmus testing with frenzel lens eyeglasses
Datatype
text
Alias
- UMLS CUI [1]
- C0028738
Beschrijving
Nystagmus testing with frenzel lens eyeglasses
Datatype
text
Alias
- UMLS CUI [1]
- C0028738
Beschrijving
Nystagmus testing with frenzel lens eyeglasses
Datatype
text
Alias
- UMLS CUI [1]
- C0028738
Beschrijving
Nystagmus testing with frenzel lens eyeglasses
Datatype
text
Alias
- UMLS CUI [1]
- C0012833
Beschrijving
Posturography
Beschrijving
Computerized dynamic posturography procedure
Datatype
text
Alias
- UMLS CUI [1]
- C0519978
Beschrijving
Computerized dynamic posturography procedure report has to be enclosed
Datatype
text
Alias
- UMLS CUI [1]
- C0519978
Beschrijving
Tasks of investigator during this visit
Beschrijving
Questionnaire
Datatype
boolean
Alias
- UMLS CUI [1]
- C0034394
Beschrijving
Trial medication
Datatype
boolean
Alias
- UMLS CUI [1]
- C0013227
Beschrijving
Trial medication
Datatype
integer
Alias
- UMLS CUI [1]
- C0013227
Beschrijving
Patient questions
Datatype
boolean
Alias
- UMLS CUI [1]
- C0547398
Beschrijving
Patient questions
Datatype
text
Alias
- UMLS CUI [1]
- C0547398
Beschrijving
Date
Datatype
date
Alias
- UMLS CUI [1]
- C0011008
Beschrijving
Signature
Datatype
text
Alias
- UMLS CUI [1]
- C1519316
Beschrijving
Comorbidities and concomitant Medication
Beschrijving
Comorbidities
Datatype
boolean
Alias
- UMLS CUI [1]
- C0009488
Beschrijving
Comorbidities
Datatype
text
Alias
- UMLS CUI [1]
- C0009488
Beschrijving
prohibited medication: -aminoglycoside antibiotics -vasoactive agents -stimulants to the central nervous system -tranquilizer -agents aiming at cell metabolism -antihistamines -Antiplatelet Agents -anticoagulants
Datatype
boolean
Alias
- UMLS CUI [1]
- C2347852
Beschrijving
Concomitant Agent
Datatype
text
Alias
- UMLS CUI [1]
- C2347852
Beschrijving
additional comments
Datatype
text
Alias
- UMLS CUI [1]
- C1830770
Beschrijving
General impression regarding the trial
Beschrijving
Tolerance
Datatype
text
Alias
- UMLS CUI [1]
- C0556444
Beschrijving
Effectiveness
Datatype
text
Alias
- UMLS CUI [1]
- C0087113
Beschrijving
Date
Datatype
date
Alias
- UMLS CUI [1]
- C0011008
Beschrijving
Signature
Datatype
text
Alias
- UMLS CUI [1]
- C1519316
Beschrijving
Adverse reactions
Beschrijving
If yes, please give further detailed information below
Datatype
boolean
Alias
- UMLS CUI [1]
- C0559546
Beschrijving
Adverse event
Datatype
text
Alias
- UMLS CUI [1]
- C0877248
Beschrijving
In case of severe or life-threatening AE, please notify URSAPHARM GmbH (ASAP< 24h) and fill in the enclosed pharmacovigilance form. Phone 06805-9292130, Fax 06805-929288
Datatype
integer
Alias
- UMLS CUI [1]
- C1710066
Beschrijving
If patient has been discontinued from trial,please enclose final report.
Datatype
text
Alias
- UMLS CUI [1]
- C0087111
Beschrijving
Development
Datatype
text
Alias
- UMLS CUI [1]
- C0243107
Beschrijving
Drug association
Datatype
text
Alias
- UMLS CUI [1]
- C0544075
Beschrijving
additional comments
Datatype
text
Alias
- UMLS CUI [1]
- C1830770
Beschrijving
Signature date
Datatype
date
Alias
- UMLS CUI [1]
- C0011008
Beschrijving
Signature
Datatype
text
Alias
- UMLS CUI [1]
- C1519316
Beschrijving
Final report
Beschrijving
discontinuation
Datatype
integer
Alias
- UMLS CUI [1]
- C0457454
Beschrijving
discontinuation
Datatype
text
Alias
- UMLS CUI [1]
- C0457454
Beschrijving
Date and time of discontinuation
Datatype
datetime
Alias
- UMLS CUI [1]
- C0011008
- UMLS CUI [2]
- C0457454
Beschrijving
Discontinuation
Datatype
text
Alias
- UMLS CUI [1]
- C0457454
Beschrijving
Discontinuation of trial
Datatype
boolean
Alias
- UMLS CUI [1,1]
- C0457454
- UMLS CUI [1,2]
- C0008976
Beschrijving
Discontinuation of trial
Datatype
date
Alias
- UMLS CUI [1]
- C0457454
- UMLS CUI [2]
- C0008976
Beschrijving
Discontinuation of trial
Datatype
text
Alias
- UMLS CUI [1]
- C0457454
- UMLS CUI [2]
- C0008976
Beschrijving
I hereby assure that I completed this form truthful and to my best knowledge.
Datatype
date
Beschrijving
I hereby assure that I completed this form truthful and to my best knowledge.
Datatype
text
Alias
- UMLS CUI [1]
- C1519316
Similar models
Case report form Visit 4
- StudyEvent: ODM
C0457454 (UMLS CUI [2])
C0008976 (UMLS CUI [1,2])
C0008976 (UMLS CUI [2])
C0008976 (UMLS CUI [2])