ID

16544

Descripción

Study Sponsor: Astellas Study Title Tolerability of QUTENZA™ When Applied After Pre-treatment With Lidocaine or Tramadol in Subjects With Peripheral Neuropathic Pain - A Randomized, Multi-center, Assessor-blinded Study Medicine or Vaccine (generic name) capsaicin Sponsor Identification Number QTZ-EC-0002 Trial Registry Identification Number(#'s) NCT01416116 EudraCT Number: 2010-023258-34 Medical Condition Neuropathic pain Phase Phase 4 http://clinicaltrials.gov/show/NCT01416116 Screening Visit, Form 1/4: Date of Visit Screening Status Informed Consent 1 Demographics Medical and Surgical History

Link

http://clinicaltrials.gov/show/NCT01416116

Palabras clave

Versiones (2)
  1. 21/7/16 21/7/16 -
  2. 23/7/16 23/7/16 -
Subido en

23 de julio de 2016

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY 4.0
Comentarios del modelo :

Puede comentar sobre el modelo de datos aquí. A través de las burbujas de diálogo en los grupos de elementos y elementos, puede agregar comentarios específicos.

Volver a los comentarios del modelo
Comentarios de grupo de elementos para :

Comentarios del elemento para :

Para descargar modelos de datos, debe haber iniciado sesión. Por favor iniciar sesión o Registrate gratis.

Screening Visit Form 1/4 Tolerability of QUTENZA™ When Applied After Pre-treatment With Lidocaine or Tramadol in Subjects With Peripheral Neuropathic Pain - A Randomized, Multi-center, Assessor-blinded Study NCT01416116

Inglés

Screening Visit Form 1/4 Tolerability of QUTENZA™ When Applied After Pre-treatment With Lidocaine or Tramadol in Subjects With Peripheral Neuropathic Pain - A Randomized, Multi-center, Assessor-blinded Study NCT01416116

1 formularios  
Date of Visit
Descripción

Date of Visit

Date of Visit
Descripción

Field name: VDDT

Tipo de datos

date

Screening Status
Descripción

Screening Status

Is the subject a screen failure (signed an informed consent but was not randomized)?
Descripción

Field Name: DSYN

Tipo de datos

integer

Alias
UMLS CUI [1]
C1710476
Reason for Not Meeting Admission Criteria
Descripción

Field Name: SFDECOD

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0030673
UMLS CUI [1,2]
C0392360
If 'Other' specify
Descripción

Field Name: SFOTHSP

Tipo de datos

text

Alias
UMLS CUI [1]
C0205394
Informed Consent 1
Descripción

Informed Consent 1

Date of Informed Consent
Descripción

DSSTDT

Tipo de datos

date

Alias
UMLS CUI [1]
C2985782
Demographics
Descripción

Demographics

Sex
Descripción

Sex

Tipo de datos

text

Alias
UMLS CUI [1]
C0079399
Birth Date
Descripción

Field Name: BRTHDT

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Age
Descripción

Field Name: Age

Tipo de datos

integer

Unidades de medida
  • Years
Alias
UMLS CUI [1]
C0001779
Years
Race
Descripción

Field Name :RACE

Tipo de datos

integer

Alias
UMLS CUI [1]
C0034510
If 'Other', specify
Descripción

Field Name: RACEOTH

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0034510
Medical and Surgical History
Descripción

Medical and Surgical History

Is there any past or present Medical Condition? If 'Yes', please provide details below
Descripción

Field Name: MHANY

Tipo de datos

integer

Alias
UMLS CUI [1]
C0012634
MedicalCondition, specify
Descripción

Field Name: MHTERM

Tipo de datos

text

Alias
UMLS CUI [1]
C0012634
Onset Date
Descripción

Field Name: MHSTDT

Tipo de datos

date

Alias
UMLS CUI [1]
C0574845
Is Medical Condition ongoing? If 'No', please provide 'Recovered Date'.
Descripción

Field Name: MHONGO

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0549178
UMLS CUI [1,2]
C0012634
Recovered Date
Descripción

Field Name: MHENDT

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0237820
UMLS CUI [1,2]
C0011008
Volver a la parte superior de la página

Similar models

Screening Visit Form 1/4 Tolerability of QUTENZA™ When Applied After Pre-treatment With Lidocaine or Tramadol in Subjects With Peripheral Neuropathic Pain - A Randomized, Multi-center, Assessor-blinded Study NCT01416116

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Date of Visit
Date of Visit
Item
Date of Visit
date
Item Group
Screening Status
Item
Is the subject a screen failure (signed an informed consent but was not randomized)?
integer
C1710476 (UMLS CUI [1])
Screen failure
Code List
Is the subject a screen failure (signed an informed consent but was not randomized)?
CL Item
No (0)
CL Item
Yes (1)
Item
Reason for Not Meeting Admission Criteria
integer
C0030673 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
no admission, reason
Code List
Reason for Not Meeting Admission Criteria
CL Item
Not fulfill inclusion or exclusion criteria (1 )
CL Item
Untoward Medical Symptoms (3 )
CL Item
Subject lost to follow up (7 )
CL Item
Other (99 )
CL Item
Withdrawal of consent (6 )
Other
Item
If 'Other' specify
text
C0205394 (UMLS CUI [1])
Item Group
Informed Consent 1
Date of Informed Consent
Item
Date of Informed Consent
date
C2985782 (UMLS CUI [1])
Item Group
Demographics
Item
Sex
text
C0079399 (UMLS CUI [1])
Sex
Code List
Sex
CL Item
Male (1)
CL Item
Female (2)
Birth Date
Item
Birth Date
date
C0421451 (UMLS CUI [1])
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Item
Race
integer
C0034510 (UMLS CUI [1])
Race
Code List
Race
CL Item
White (1 )
CL Item
Black or African American (3 )
CL Item
Asian (4 )
CL Item
American Indian or Alaskan Native (5 )
CL Item
Native Hawaiian or Other Pacific Islander (6 )
CL Item
Other (99 )
Other race
Item
If 'Other', specify
text
C0205394 (UMLS CUI [1,1])
C0034510 (UMLS CUI [1,2])
Item Group
Medical and Surgical History
Item
Is there any past or present Medical Condition? If 'Yes', please provide details below
integer
C0012634 (UMLS CUI [1])
medical condition
Code List
Is there any past or present Medical Condition? If 'Yes', please provide details below
CL Item
No (0 )
CL Item
Yes (1 )
Medical Condition
Item
MedicalCondition, specify
text
C0012634 (UMLS CUI [1])
Onset Date
Item
Onset Date
date
C0574845 (UMLS CUI [1])
Item
Is Medical Condition ongoing? If 'No', please provide 'Recovered Date'.
integer
C0549178 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
ongoing
Code List
Is Medical Condition ongoing? If 'No', please provide 'Recovered Date'.
CL Item
No (0 )
CL Item
Yes (1 )
date of recovery
Item
Recovered Date
date
C0237820 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Volver a la parte superior de la página 

Contacto

Utilice este formulario para comentarios, preguntas y sugerencias.

Los campos marcados con * son obligatorios.

Ayuda

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial