Inglés

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

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General Information
Descripción

General Information

Center Number
Descripción

Center Number

Tipo de datos

integer

Patient No
Descripción

patient number

Tipo de datos

integer

Patient Initials
Descripción

Patient Initials

Tipo de datos

text

Form D
Descripción

Form D

Certified cause of death
Descripción

Certified cause of death

Tipo de datos

text

Date of death
Descripción

Date of death

Tipo de datos

date

Was a post-mortem carried out?
Descripción

Post-mortem

Tipo de datos

text

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

Post-mortem findings

Tipo de datos

text

Reporting Physician´s Signature
Descripción

Reporting Physician´s Signature

Tipo de datos

text

Date
Descripción

Date

Tipo de datos

date

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Similar models

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

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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