ID
13030
Beskrivning
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
Nyckelord
Versioner (1)
- 2016-01-12 2016-01-12 -
Uppladdad den
12 januari 2016
DOI
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Licens
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
Beskrivning
otorhinolaryngologic examination
Beskrivning
Otoscopy
Datatyp
text
Alias
- UMLS CUI [1]
- C0419361
Beskrivning
Otoscopy
Datatyp
text
Alias
- UMLS CUI [1]
- C0419361
Beskrivning
Rinne test
Datatyp
text
Alias
- UMLS CUI [1]
- C0278245
Beskrivning
Rinne test
Datatyp
text
Alias
- UMLS CUI [1]
- C0278245
Beskrivning
Webers test
Datatyp
text
Alias
- UMLS CUI [1]
- C0278247
Beskrivning
Webers test
Datatyp
text
Alias
- UMLS CUI [1]
- C0278247
Beskrivning
Nystagmus testing with frenzel lens eyeglasses
Datatyp
text
Alias
- UMLS CUI [1]
- C0028738
Beskrivning
Nystagmus testing with frenzel lens eyeglasses
Datatyp
text
Alias
- UMLS CUI [1]
- C0028738
Beskrivning
Nystagmus testing with frenzel lens eyeglasses
Datatyp
text
Alias
- UMLS CUI [1]
- C0028738
Beskrivning
Nystagmus testing with frenzel lens eyeglasses
Datatyp
text
Alias
- UMLS CUI [1]
- C0012833
Beskrivning
Posturography
Beskrivning
Computerized dynamic posturography procedure
Datatyp
text
Alias
- UMLS CUI [1]
- C0519978
Beskrivning
Computerized dynamic posturography procedure report has to be enclosed
Datatyp
text
Alias
- UMLS CUI [1]
- C0519978
Beskrivning
Tasks of investigator during this visit
Beskrivning
Questionnaire
Datatyp
boolean
Alias
- UMLS CUI [1]
- C0034394
Beskrivning
Trial medication
Datatyp
boolean
Alias
- UMLS CUI [1]
- C0013227
Beskrivning
Trial medication
Datatyp
integer
Alias
- UMLS CUI [1]
- C0013227
Beskrivning
Patient questions
Datatyp
boolean
Alias
- UMLS CUI [1]
- C0547398
Beskrivning
Patient questions
Datatyp
text
Alias
- UMLS CUI [1]
- C0547398
Beskrivning
Date
Datatyp
date
Alias
- UMLS CUI [1]
- C0011008
Beskrivning
Signature
Datatyp
text
Alias
- UMLS CUI [1]
- C1519316
Beskrivning
Comorbidities and concomitant Medication
Beskrivning
Comorbidities
Datatyp
boolean
Alias
- UMLS CUI [1]
- C0009488
Beskrivning
Comorbidities
Datatyp
text
Alias
- UMLS CUI [1]
- C0009488
Beskrivning
prohibited medication: -aminoglycoside antibiotics -vasoactive agents -stimulants to the central nervous system -tranquilizer -agents aiming at cell metabolism -antihistamines -Antiplatelet Agents -anticoagulants
Datatyp
boolean
Alias
- UMLS CUI [1]
- C2347852
Beskrivning
Concomitant Agent
Datatyp
text
Alias
- UMLS CUI [1]
- C2347852
Beskrivning
additional comments
Datatyp
text
Alias
- UMLS CUI [1]
- C1830770
Beskrivning
General impression regarding the trial
Beskrivning
Tolerance
Datatyp
text
Alias
- UMLS CUI [1]
- C0556444
Beskrivning
Effectiveness
Datatyp
text
Alias
- UMLS CUI [1]
- C0087113
Beskrivning
Date
Datatyp
date
Alias
- UMLS CUI [1]
- C0011008
Beskrivning
Signature
Datatyp
text
Alias
- UMLS CUI [1]
- C1519316
Beskrivning
Adverse reactions
Beskrivning
If yes, please give further detailed information below
Datatyp
boolean
Alias
- UMLS CUI [1]
- C0559546
Beskrivning
Adverse event
Datatyp
text
Alias
- UMLS CUI [1]
- C0877248
Beskrivning
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
Datatyp
integer
Alias
- UMLS CUI [1]
- C1710066
Beskrivning
If patient has been discontinued from trial,please enclose final report.
Datatyp
text
Alias
- UMLS CUI [1]
- C0087111
Beskrivning
Development
Datatyp
text
Alias
- UMLS CUI [1]
- C0243107
Beskrivning
Drug association
Datatyp
text
Alias
- UMLS CUI [1]
- C0544075
Beskrivning
additional comments
Datatyp
text
Alias
- UMLS CUI [1]
- C1830770
Beskrivning
Signature date
Datatyp
date
Alias
- UMLS CUI [1]
- C0011008
Beskrivning
Signature
Datatyp
text
Alias
- UMLS CUI [1]
- C1519316
Beskrivning
Final report
Beskrivning
discontinuation
Datatyp
integer
Alias
- UMLS CUI [1]
- C0457454
Beskrivning
discontinuation
Datatyp
text
Alias
- UMLS CUI [1]
- C0457454
Beskrivning
Date and time of discontinuation
Datatyp
datetime
Alias
- UMLS CUI [1]
- C0011008
- UMLS CUI [2]
- C0457454
Beskrivning
Discontinuation
Datatyp
text
Alias
- UMLS CUI [1]
- C0457454
Beskrivning
Discontinuation of trial
Datatyp
boolean
Alias
- UMLS CUI [1,1]
- C0457454
- UMLS CUI [1,2]
- C0008976
Beskrivning
Discontinuation of trial
Datatyp
date
Alias
- UMLS CUI [1]
- C0457454
- UMLS CUI [2]
- C0008976
Beskrivning
Discontinuation of trial
Datatyp
text
Alias
- UMLS CUI [1]
- C0457454
- UMLS CUI [2]
- C0008976
Beskrivning
I hereby assure that I completed this form truthful and to my best knowledge.
Datatyp
date
Beskrivning
I hereby assure that I completed this form truthful and to my best knowledge.
Datatyp
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])