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

1 Formulários  
Screening Baseline Conclusion
Descrição

Screening Baseline Conclusion

Will the patient be continued in the study?
Descrição

Will the patient be continued in the study?

Tipo de dados

integer

If withdrawn, please mark primary reason below.
Descrição

Primary reason for withdrawal

Tipo de dados

text

If other reason for withdrawal, please specify
Descrição

Specification of other reason for withdrawal

Tipo de dados

text

Investigator´s signature
Descrição

Investigator´s signature

Investigator´s signature
Descrição

I certify that I have reviewed the data in this case report form up to this point and that all the information is complete and accurate.

Tipo de dados

text

Date
Descrição

Date

Tipo de dados

date

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

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Screening Baseline Conclusion
Item
Will the patient be continued in the study?
integer
Will the patient be continued in the study?
Code List
Will the patient be continued in the study?
CL Item
Yes (1)
CL Item
No (If No, please mark the PRIMARY reason of exclusion/withdrawal below) (2)
Item
If withdrawn, please mark primary reason below.
text
Primary reason for withdrawal
Code List
If withdrawn, please mark primary reason below.
CL Item
Baseline adverse experience (Complete BAE form) (1)
CL Item
Does not meet inclusion/exclusion criteria (2)
CL Item
Protocol deviation (including non-compliance) (3)
CL Item
Lost to follow-up (4)
CL Item
Other, specify... (5)
Specification of other reason for withdrawal
Item
If other reason for withdrawal, please specify
text
Item Group
Investigator´s signature
Investigator´s signature
Item
Investigator´s signature
text
Date
Item
Date
date
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