Engelsk

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

1 Formulär  
Screening Baseline Conclusion
Beskrivning

Screening Baseline Conclusion

Will the patient be continued in the study?
Beskrivning

Will the patient be continued in the study?

Datatyp

integer

If withdrawn, please mark primary reason below.
Beskrivning

Primary reason for withdrawal

Datatyp

text

If other reason for withdrawal, please specify
Beskrivning

Specification of other reason for withdrawal

Datatyp

text

Investigator´s signature
Beskrivning

Investigator´s signature

Investigator´s signature
Beskrivning

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.

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

Tillbaka till toppen

Similar models

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

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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If withdrawn, please mark primary reason below.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If withdrawn, please mark primary reason below.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
Tillbaka till toppen