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Concomitant Medication Section GSK Ropinirole Restless Legs Syndrome 101468

1 forms  
Patient Information
Description

Patient Information

Alias
UMLS CUI-1
C1955348
Patient Number
Description

Patient Number

Data type

text

Alias
UMLS CUI [1]
C1830427
Centre Number
Description

Centre Number

Data type

text

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0019994
Visit Day
Description

Visit Day

Data type

date

Measurement units
  • dd-mmm-yyyy
Alias
UMLS CUI [1]
C2827038
dd-mmm-yyyy
Concomitant Medication - If Medical History section is included indications on Prior Medication page must correlate utilizing the same terminlogy. Indication on concomitant page must be recorded on the Adverse Events Page and expressed utilizing the same terminology. If a medication was marked continuing at the initial visit (On the Prior and Concomitant Medication Page), but has since had a dosage change or has been stopped, it must be recorded on this form as a change with the start and end date.
Description

Concomitant Medication - If Medical History section is included indications on Prior Medication page must correlate utilizing the same terminlogy. Indication on concomitant page must be recorded on the Adverse Events Page and expressed utilizing the same terminology. If a medication was marked continuing at the initial visit (On the Prior and Concomitant Medication Page), but has since had a dosage change or has been stopped, it must be recorded on this form as a change with the start and end date.

Alias
UMLS CUI-1
C2347852
Are there any concomitant medication CHANGES since the start of the study?
Description

If "YES", please record all medications used below. Where appropriate, medical conditions should be recorded on the Adverse Events Form, utilizing the same terminology. If a medication has had a dosage change it must be recorded with the start and stop date.

Data type

boolean

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C0443172
Drug Name (Trade Name Preferred)
Description

Drug Name

Data type

text

Alias
UMLS CUI [1]
C0013227
SINGLE Dose/Unit (e.g. 500mg)
Description

Dose

Data type

text

Alias
UMLS CUI [1]
C3174092
Frequency of this Dose (e.g. BID, PRN)
Description

Dose Frequency

Data type

text

Alias
UMLS CUI [1]
C2826654
Route
Description

Administration Route

Data type

text

Indication
Description

Indication

Data type

text

Alias
UMLS CUI [1]
C3146298
Start Date
Description

Start Date - As a minimum the year must be started.

Data type

date

Measurement units
  • dd-mmm-yyyy
dd-mmm-yyyy
Start Time
Description

Start Time

Data type

time

Measurement units
  • 24hr:min
Alias
UMLS CUI [1]
C1301880
24hr:min
End Date
Description

End Date

Data type

date

Measurement units
  • dd-mmm-yyyy
Alias
UMLS CUI [1]
C0806020
dd-mmm-yyyy
End Time
Description

End Time

Data type

time

Measurement units
  • 24hr:min
Alias
UMLS CUI [1]
C1522314
24hr:min
Continuiing at end of Study?
Description

Ongoing

Data type

boolean

Alias
UMLS CUI [1]
C0549178
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Similar models

Concomitant Medication Section GSK Ropinirole Restless Legs Syndrome 101468

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient Information
C1955348 (UMLS CUI-1)
Patient Number
Item
Patient Number
text
C1830427 (UMLS CUI [1])
Centre Number
Item
Centre Number
text
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Visit Day
Item
Visit Day
date
C2827038 (UMLS CUI [1])
Item Group
Concomitant Medication - If Medical History section is included indications on Prior Medication page must correlate utilizing the same terminlogy. Indication on concomitant page must be recorded on the Adverse Events Page and expressed utilizing the same terminology. If a medication was marked continuing at the initial visit (On the Prior and Concomitant Medication Page), but has since had a dosage change or has been stopped, it must be recorded on this form as a change with the start and end date.
C2347852 (UMLS CUI-1)
Change of Concomitant Medication
Item
Are there any concomitant medication CHANGES since the start of the study?
boolean
C2347852 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Drug Name
Item
Drug Name (Trade Name Preferred)
text
C0013227 (UMLS CUI [1])
Dose
Item
SINGLE Dose/Unit (e.g. 500mg)
text
C3174092 (UMLS CUI [1])
Dose Frequency
Item
Frequency of this Dose (e.g. BID, PRN)
text
C2826654 (UMLS CUI [1])
Item
Route
text
Administration Route
Code List
Route
CL Item
intra-articular (IA)
CL Item
intra-arterial (IAR)
CL Item
intra-dermal (ID)
CL Item
inhalation (IH)
CL Item
intra-muscular (IM)
CL Item
intra-thecal (IT)
CL Item
intra-venous (IV)
CL Item
nasal (NA)
CL Item
oral (PO)
CL Item
rectal (PR)
CL Item
subcutaneous (SC)
CL Item
sublingual (SL)
CL Item
transdermal (TD)
CL Item
topical (TO)
CL Item
vaginal (VA)
Indication
Item
Indication
text
C3146298 (UMLS CUI [1])
Start Date
Item
Start Date
date
Start Time
Item
Start Time
time
C1301880 (UMLS CUI [1])
End Date
Item
End Date
date
C0806020 (UMLS CUI [1])
End Time
Item
End Time
time
C1522314 (UMLS CUI [1])
Ongoing
Item
Continuiing at end of Study?
boolean
C0549178 (UMLS CUI [1])
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