ID

24822

Descripción

Study part: Patient Enrollment Form Patient Continuation/ Withdrawal. A 52 Week Open-Label Extension Study of the Long-Term Safety of Ropinirole in Subjects Suffering from Restless Legs Syndrome (RLS). Patient Level Data: Study Listed on ClinicalStudyDataRequest.com. Phase: phase 3. Study Recruitment Status: Completed. Generic Name: ropinirole. Trade Name: Modutab,ZIPEREVE,ZEPREVE,REPREVE,ADARTREL,REQUIP,Zygara; Zygara,ZIPEREVE,ZEPREVE,Requip Depot,REQUIP,REPREVE,Modutab,ADARTREL. Study Indication : Restless Legs Syndrome. Study ID: 101468/192. Clinical Study ID: 101468/192

Palabras clave

Versiones (2)
  1. 19/8/17 19/8/17 -
  2. 13/3/19 13/3/19 -
Titular de derechos de autor

GlaxoSmithKline

Subido en

19 de agosto de 2017

DOI

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Licencia

Creative Commons BY-NC 3.0
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Patient Enrollment Form Patient Continuation/ Withdrawal Ropinirole Restless Legs Syndrom 101468/192

Inglés

Patient Enrollment Form Patient Continuation/ Withdrawal

1 formularios  
PATIENT ENROLMENT FORM
Descripción

PATIENT ENROLMENT FORM

Alias
UMLS CUI-1
C4041024
To
Descripción

Received By

Tipo de datos

text

Alias
UMLS CUI [1]
C1709850
Fax No.:
Descripción

Fax Number

Tipo de datos

integer

Alias
UMLS CUI [1]
C1549619
The following patient has been enroled in study: 101468/
Descripción

study subject participation status

Tipo de datos

integer

Alias
UMLS CUI [1]
C2348568
Patient Initials
Descripción

Patient Initials

Tipo de datos

text

Alias
UMLS CUI [1]
C2986440
Patient Number
Descripción

Patient Number

Tipo de datos

integer

Alias
UMLS CUI [1]
C1830427
Centre Number
Descripción

Centre Number

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0019994
Date of enrollment:
Descripción

Date of enrollment

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0679646
UMLS CUI [1,3]
C1516879
Signed:
Descripción

Signed

Tipo de datos

text

Alias
UMLS CUI [1]
C1561610
Date:
Descripción

Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0011008
Please print name:
Descripción

print name

Tipo de datos

text

Alias
UMLS CUI [1]
C0027365
Institution:
Descripción

Institution

Tipo de datos

text

Alias
UMLS CUI [1]
C1301943
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Similar models

Patient Enrollment Form Patient Continuation/ Withdrawal

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
PATIENT ENROLMENT FORM
C4041024 (UMLS CUI-1)
Received By
Item
To
text
C1709850 (UMLS CUI [1])
Fax Number
Item
Fax No.:
integer
C1549619 (UMLS CUI [1])
study subject participation status
Item
The following patient has been enroled in study: 101468/
integer
C2348568 (UMLS CUI [1])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Patient Number
Item
Patient Number
integer
C1830427 (UMLS CUI [1])
Centre Number
Item
Centre Number
integer
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Date of enrollment
Item
Date of enrollment:
date
C0011008 (UMLS CUI [1,1])
C0679646 (UMLS CUI [1,2])
C1516879 (UMLS CUI [1,3])
Signed
Item
Signed:
text
C1561610 (UMLS CUI [1])
Date
Item
Date:
date
C0011008 (UMLS CUI [1])
print name
Item
Please print name:
text
C0027365 (UMLS CUI [1])
Institution
Item
Institution:
text
C1301943 (UMLS CUI [1])
Volver a la parte superior de la página 

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