ID

25338

Beskrivning

Study ID: 101468/191 Clinical Study ID: SKF-101468/191 Study Title:A 12 Week, Double-Blind, Placebo-Controlled, Parallel Group Study to Assess the Efficacy, Safety and Tolerability of Ropinirole in Subjects with Restless Legs Syndrome (RLS) Suffering from Periodic Leg Movements of Sleep (PLMS) Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Requip Study Indication: Restless Legs Syndrome

Nyckelord

Versioner (2)
  1. 2017-09-01 2017-09-01 -
  2. 2017-09-01 2017-09-01 -
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1 september 2017

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Creative Commons BY-NC 3.0
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GSK Ropinirole in Subjects with Restless Legs Syndrome 101468/191 Week 12 Day (Form 16)

Engelsk

GSK Ropinirole in Subjects with Restless Legs Syndrome 101468/191 Week 12 Day (Form 16)

1 Formulär  
General Information
Beskrivning

General Information

Center Number
Beskrivning

Center Number

Datatyp

integer

Patient Number
Beskrivning

Patient Number

Datatyp

integer

Patient Initials
Beskrivning

Patient Initials

Datatyp

text

Visit Date
Beskrivning

Visit Date

Datatyp

date

Investigational Product Record since last visit
Beskrivning

Investigational Product Record since last visit

Please complete the investigational product record in the Investigational Product and Compliance Section at the back of this book. Please complete the Investigational Product Interruption record in the Investigational Product and Compliance Section at the back of this book.
Beskrivning

Investigational Product Record since last visit

Datatyp

boolean

RSL Rating Scale
Beskrivning

RSL Rating Scale

INVESTIGATOR: Please complete the appropriate RLS Rating Scale from the RLS Rating Scale Book.
Beskrivning

RSL Rating Scale

Datatyp

boolean

Vital Signs
Beskrivning

Vital Signs

Weight (without shoes)
Beskrivning

Weight

Datatyp

float

Måttenheter
  • kg/lbs
kg/lbs
Pulse (after 5 minutes sitting)
Beskrivning

Pulse

Datatyp

integer

Måttenheter
  • beats/min
beats/min
Sitting Blood Pressure (after 5 minutes sitting) systolic
Beskrivning

Sitting Blood Pressure systolic

Datatyp

integer

Måttenheter
  • mmHg
mmHg
Sitting Blood pressure (after 5 minutes sitting) diastolic
Beskrivning

Sitting Blood pressure diastolic

Datatyp

integer

Måttenheter
  • mmHg
mmHg
Please record any medical procedures performed since the last visit in the Medical Procedures section at the back of this book.
Beskrivning

Medical Procedures

Datatyp

boolean

Please record any changes in concomitant medication since the last visit in the Concomitant Medication section at the back of this book.
Beskrivning

Concomitant Medication

Datatyp

boolean

Please record any adverse experiences observed or elicited by the following direct question to the patient: "Have you felt different in any way since the Week 8 Visit?" in the Adverse Experience section at the back of this book.
Beskrivning

Adverse Experiences

Datatyp

boolean

Laboratory Evaluation
Beskrivning

Laboratory Evaluation

Date of blood sample
Beskrivning

Date of blood sample

Datatyp

date

Were any clinically significant abnormalities detected?
Beskrivning

Results

Datatyp

text

Pregnancy Dipstick
Beskrivning

Pregnancy Dipstick

Is the patient a female of childbearing potential?
Beskrivning

Pregnancy Dipstick

Datatyp

text

Results pregnancy dipstick
Beskrivning

Results pregnancy dipstick

Datatyp

text

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Similar models

GSK Ropinirole in Subjects with Restless Legs Syndrome 101468/191 Week 12 Day (Form 16)

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
General Information
Center Number
Item
Center Number
integer
Patient Number
Item
Patient Number
integer
Patient Initials
Item
Patient Initials
text
Visit Date
Item
Visit Date
date
Item Group
Investigational Product Record since last visit
Investigational Product Record since last visit
Item
Please complete the investigational product record in the Investigational Product and Compliance Section at the back of this book. Please complete the Investigational Product Interruption record in the Investigational Product and Compliance Section at the back of this book.
boolean
Item Group
RSL Rating Scale
RSL Rating Scale
Item
INVESTIGATOR: Please complete the appropriate RLS Rating Scale from the RLS Rating Scale Book.
boolean
Item Group
Vital Signs
Weight
Item
Weight (without shoes)
float
Pulse
Item
Pulse (after 5 minutes sitting)
integer
Sitting Blood Pressure systolic
Item
Sitting Blood Pressure (after 5 minutes sitting) systolic
integer
Sitting Blood pressure diastolic
Item
Sitting Blood pressure (after 5 minutes sitting) diastolic
integer
Medical Procedures
Item
Please record any medical procedures performed since the last visit in the Medical Procedures section at the back of this book.
boolean
Concomitant Medication
Item
Please record any changes in concomitant medication since the last visit in the Concomitant Medication section at the back of this book.
boolean
Adverse Experiences
Item
Please record any adverse experiences observed or elicited by the following direct question to the patient: "Have you felt different in any way since the Week 8 Visit?" in the Adverse Experience section at the back of this book.
boolean
Item Group
Laboratory Evaluation
Date of blood sample
Item
Date of blood sample
date
Item
Were any clinically significant abnormalities detected?
text
Results
Code List
Were any clinically significant abnormalities detected?
CL Item
No (1)
CL Item
Yes -> If "Positive", please record details in the Pregnancy Information section on the Study Conclusion page at the back of this book. (2)
Item Group
Pregnancy Dipstick
Item
Is the patient a female of childbearing potential?
text
Pregnancy Dipstick
Code List
Is the patient a female of childbearing potential?
CL Item
No (1)
CL Item
Yes -> If "Yes", please perform a pregnancy dipstick test and record results below. (2)
Item
Results pregnancy dipstick
text
Results pregnancy dipstick
Code List
Results pregnancy dipstick
CL Item
Negative (1)
CL Item
Positive -> If "Posititve", please record details in the Pregnancy Information section on the Study Conclusion page at the end of this book. (2)
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