Englisch

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

1 Formulare  
Patient continuation / withdrawal
Beschreibung

Patient continuation / withdrawal

Is the patient continuing in the study?
Beschreibung

Is the patient continuing in the study?

Datentyp

integer

Reason for withdrawal
Beschreibung

Reason for withdrawal

Datentyp

integer

If other reason for withdrawal, please specify
Beschreibung

Specification of other reason for withdrawal

Datentyp

text

Date of last dose
Beschreibung

Date of last dose

Datentyp

date

Investigator´s signature
Beschreibung

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

Datentyp

text

Date
Beschreibung

Date

Datentyp

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 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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