Engels

GSK Ropinirole in Subjects with Restless Legs Syndrome 101468/191 Form D (Form 23)

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General Information
Beschrijving

General Information

Center Number
Beschrijving

Center Number

Datatype

integer

Patient No
Beschrijving

patient number

Datatype

integer

Patient Initials
Beschrijving

Patient Initials

Datatype

text

Form D
Beschrijving

Form D

Certified cause of death
Beschrijving

Certified cause of death

Datatype

text

Date of death
Beschrijving

Date of death

Datatype

date

Was a post-mortem carried out?
Beschrijving

Post-mortem

Datatype

text

If post-mortem was carried out, please summarize findings (include diagnosis)
Beschrijving

Post-mortem findings

Datatype

text

Reporting Physician´s Signature
Beschrijving

Reporting Physician´s Signature

Datatype

text

Date
Beschrijving

Date

Datatype

date

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GSK Ropinirole in Subjects with Restless Legs Syndrome 101468/191 Form D (Form 23)

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
General Information
Center Number
Item
Center Number
integer
patient number
Item
Patient No
integer
Patient Initials
Item
Patient Initials
text
Item Group
Form D
Certified cause of death
Item
Certified cause of death
text
Date of death
Item
Date of death
date
Item
Was a post-mortem carried out?
text
Post-mortem
Code List
Was a post-mortem carried out?
CL Item
No (1)
CL Item
Yes -> If "Yes" please summarize findings (including diagnosis) below (2)
Post-mortem findings
Item
If post-mortem was carried out, please summarize findings (include diagnosis)
text
Reporting Physician´s Signature
Item
Reporting Physician´s Signature
text
Date
Item
Date
date
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