Engelsk

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

1 Formulär  
General Information
Beskrivning

General Information

Center Number
Beskrivning

Center Number

Datatyp

integer

Patient No
Beskrivning

patient number

Datatyp

integer

Patient Initials
Beskrivning

Patient Initials

Datatyp

text

Form D
Beskrivning

Form D

Certified cause of death
Beskrivning

Certified cause of death

Datatyp

text

Date of death
Beskrivning

Date of death

Datatyp

date

Was a post-mortem carried out?
Beskrivning

Post-mortem

Datatyp

text

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

Post-mortem findings

Datatyp

text

Reporting Physician´s Signature
Beskrivning

Reporting Physician´s Signature

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

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Similar models

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

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 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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