ID

26204

Beschreibung

Study ID: 101468/125 Clinical Study ID: SKF-101468/125 Study Title: A double-blind, multicentre, flexible dose, L-dopa controlled study of ropinirole to investigate A) neuroprotective effect as measured by 3D PET scanning, and B) ophthalmological safety, in patients with early Parkinson’s disease Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: requip Study Indication: Restless Legs Syndrome

Stichworte

Versionen (1)
  1. 11.10.17 11.10.17 -
Rechteinhaber

GlaxoSmithKline

Hochgeladen am

11. Oktober 2017

DOI

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Creative Commons BY-NC 3.0
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L-dopa controlled study of ropinirole, neuroprotective effect and ophthalmological safety in early Parkinson’s disease 101468/125 Module 1 Visit 2 Baseline

Englisch

L-dopa controlled study of ropinirole, neuroprotective effect and ophthalmological safety in early Parkinson’s disease 101468/125 Module 1 Visit 2 Baseline

1 Formulare  
General Information
Beschreibung

General Information

Centre Number
Beschreibung

Centre Number

Datentyp

integer

Patient Number
Beschreibung

Patient Number

Datentyp

integer

Patient Initials
Beschreibung

Patient Initials

Datentyp

text

Visit Date
Beschreibung

Visit Date

Datentyp

date

Reminder laboratory test results: Ensure that the clinically significant laboratory values question on page 8 has been answered.
Beschreibung

Reminder laboratory test results

Datentyp

text

Vital signs
Beschreibung

Vital signs

Sitting blood pressure (systolic)
Beschreibung

Sitting blood pressure (systolic)

Datentyp

integer

Maßeinheiten
  • mmHg
mmHg
Sitting blood pressure (diastolic)
Beschreibung

Sitting blood pressure (diastolic)

Datentyp

integer

Maßeinheiten
  • mmHg
mmHg
Sitting heart rate
Beschreibung

Sitting heart rate

Datentyp

integer

Maßeinheiten
  • beats/min
beats/min
Baseline Adverse Experiences
Beschreibung

Baseline Adverse Experiences

Experience
Beschreibung

Experience

Datentyp

text

For SB
Beschreibung

For SB

Datentyp

text

Date Started
Beschreibung

Date Started

Datentyp

date

Date stopped
Beschreibung

Date stopped

Datentyp

date

Duration if less than 24hrs
Beschreibung

Duration if less than 24hrs

Datentyp

float

Maßeinheiten
  • hrs
hrs
Experience continuing at end of Baseline Visit
Beschreibung

Experience continuing at end of Baseline Visit

Datentyp

boolean

Course: Continuous
Beschreibung

Course

Datentyp

boolean

Course: If No, no of episodes
Beschreibung

Course (nr. of episodes)

Datentyp

integer

Intensity
Beschreibung

Intensity

Datentyp

integer

Corrective therapy
Beschreibung

Corrective therapy

Datentyp

text

Do you consider this a serious baseline adverse experience by the Baseline Adverse Experience Definitions
Beschreibung

Serious Baseline Adverse Experience

Datentyp

boolean

Investigator´s Signature
Beschreibung

Investigator´s Signature

Investigator´s Signature
Beschreibung

Investigator´s Signature

Datentyp

text

Date
Beschreibung

Date

Datentyp

date

Study Medication Compliance
Beschreibung

Study Medication Compliance

Has the patient been compliant with study medication? (Compliance is defined as taking between approximately 80%-120% of medication)
Beschreibung

Study Medication Compliance

Datentyp

text

Patient eligibility
Beschreibung

Patient eligibility

Patient eligibility
Beschreibung

Patient eligibility

Datentyp

boolean

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Ähnliche Modelle

L-dopa controlled study of ropinirole, neuroprotective effect and ophthalmological safety in early Parkinson’s disease 101468/125 Module 1 Visit 2 Baseline

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
General Information
Centre Number
Item
Centre Number
integer
Patient Number
Item
Patient Number
integer
Patient Initials
Item
Patient Initials
text
Visit Date
Item
Visit Date
date
Reminder laboratory test results
Item
Reminder laboratory test results: Ensure that the clinically significant laboratory values question on page 8 has been answered.
text
Item Group
Vital signs
Sitting blood pressure (systolic)
Item
Sitting blood pressure (systolic)
integer
Sitting blood pressure (diastolic)
Item
Sitting blood pressure (diastolic)
integer
Sitting heart rate
Item
Sitting heart rate
integer
Item Group
Baseline Adverse Experiences
Experience
Item
Experience
text
For SB
Item
For SB
text
Date Started
Item
Date Started
date
Date stopped
Item
Date stopped
date
Duration if less than 24hrs
Item
Duration if less than 24hrs
float
Experience continuing at end of Baseline Visit
Item
Experience continuing at end of Baseline Visit
boolean
Course
Item
Course: Continuous
boolean
Course (nr. of episodes)
Item
Course: If No, no of episodes
integer
Item
Intensity
integer
Intensity
Code List
Intensity
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Item
Corrective therapy
text
Corrective therapy
Code List
Corrective therapy
CL Item
Yes (If "Yes" record any medication on Concomitant Medication form) (1)
CL Item
No (2)
Serious Baseline Adverse Experience
Item
Do you consider this a serious baseline adverse experience by the Baseline Adverse Experience Definitions
boolean
Item Group
Investigator´s Signature
Investigator´s Signature
Item
Investigator´s Signature
text
Date
Item
Date
date
Item Group
Study Medication Compliance
Item
Has the patient been compliant with study medication? (Compliance is defined as taking between approximately 80%-120% of medication)
text
Study Medication Compliance
Code List
Has the patient been compliant with study medication? (Compliance is defined as taking between approximately 80%-120% of medication)
CL Item
No (If "No" the patient is not eligible to continue in the study.) (1)
CL Item
Yes (2)
Item Group
Patient eligibility
Patient eligibility
Item
Patient eligibility
boolean
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