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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 forms  
Screening Baseline Conclusion
Description

Screening Baseline Conclusion

Will the patient be continued in the study?
Description

Will the patient be continued in the study?

Data type

integer

If withdrawn, please mark primary reason below.
Description

Primary reason for withdrawal

Data type

text

If other reason for withdrawal, please specify
Description

Specification of other reason for withdrawal

Data type

text

Investigator´s signature
Description

Investigator´s signature

Investigator´s signature
Description

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.

Data type

text

Date
Description

Date

Data type

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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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If withdrawn, please mark primary reason below.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If withdrawn, please mark primary reason below.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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