Inglese

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

1 moduli  
General Information
Descrizione

General Information

Center Number
Descrizione

Center Number

Tipo di dati

integer

Patient No
Descrizione

patient number

Tipo di dati

integer

Patient Initials
Descrizione

Patient Initials

Tipo di dati

text

Form D
Descrizione

Form D

Certified cause of death
Descrizione

Certified cause of death

Tipo di dati

text

Date of death
Descrizione

Date of death

Tipo di dati

date

Was a post-mortem carried out?
Descrizione

Post-mortem

Tipo di dati

text

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

Post-mortem findings

Tipo di dati

text

Reporting Physician´s Signature
Descrizione

Reporting Physician´s Signature

Tipo di dati

text

Date
Descrizione

Date

Tipo di dati

date

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Similar models

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

1 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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