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

1 Formulär  
Patient continuation / withdrawal
Beskrivning

Patient continuation / withdrawal

Is the patient continuing in the study?
Beskrivning

Is the patient continuing in the study?

Datatyp

integer

Reason for withdrawal
Beskrivning

Reason for withdrawal

Datatyp

integer

If other reason for withdrawal, please specify
Beskrivning

Specification of other reason for withdrawal

Datatyp

text

Date of last dose
Beskrivning

Date of last dose

Datatyp

date

Investigator´s signature
Beskrivning

I certify that I have reviewed the data in this module and that all the information is complete and accurate.

Datatyp

text

Date
Beskrivning

Date

Datatyp

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 Patient Continuation / Withdrawal

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patient continuation / withdrawal
Item
Is the patient continuing in the study?
integer
Is the patient continuing in the study?
Code List
Is the patient continuing in the study?
CL Item
Yes (1)
CL Item
No (If "No" mark the one most appropriate reason below, and record the date the patient last took the study medication) (2)
Item
Reason for withdrawal
integer
Reason for withdrawal
Code List
Reason for withdrawal
CL Item
Adverse experience (complete Adverse Experience section) (1)
CL Item
Lack of Efficacy  (2)
CL Item
Deviation from protocol (including non-compliance/protocol violation) (3)
CL Item
Lost to follow-up (4)
CL Item
Other (please specify below) (5)
Specification of other reason for withdrawal
Item
If other reason for withdrawal, please specify
text
Date of last dose
Item
Date of last dose
date
Investigator´s signature
Item
Investigator´s signature
text
Date
Item
Date
date
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