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Adverse Events Ropinirole in Parkinson's Disease GSK 101468/196

1 Formulär  
Patient Information
Beskrivning

Patient Information

Alias
UMLS CUI-1
C1955348
Patient No.
Beskrivning

Patient Number

Datatyp

text

Alias
UMLS CUI [1]
C1830427
Adverse Events
Beskrivning

Adverse Events

Alias
UMLS CUI-1
C0877248
Has the patient experienced any new and/or worsening adverse events from the time of Study 196 Completion Visit through the end of the Treatment Period? This CRF will only be used by subjects who have re-enrolled in the study after completion at 36 months. Other subjects (who didn't have to re-enroll) can continus using original CRFs.
Beskrivning

If YES, indicate below.

Datatyp

boolean

Alias
UMLS CUI [1]
C0877248
Adverse Event:
Beskrivning

Adverse Event Diagnosis

Datatyp

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0011900
Adverse Event: Serious?*
Beskrivning

* A Serious Adverse Event is any AE that is fatal, life-threatening , disabling/incapacitating, results in inpatient hospitalization or prolongation of existing hospitalization, or a congenital anomaly/birth defect. Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgement, they may jeopardise the patient and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. Cancer, overdose and pregnancy must also be reported on SAE form. Record any Serious Adverse Events on the Serious Adverse Event from and notify the PAREXEL Clinical Trial Safety Center within 24 hours of learning of its occurence

Datatyp

boolean

Alias
UMLS CUI [1]
C1710056
Start Date
Beskrivning

Start Date

Datatyp

date

Måttenheter
  • dd-mmm-yyyy
Alias
UMLS CUI [1]
C0808070
dd-mmm-yyyy
Start Time
Beskrivning

Start Time

Datatyp

time

Måttenheter
  • 24hr:min
Alias
UMLS CUI [1]
C1301880
24hr:min
Stop Date
Beskrivning

If ongoing, please eave blank.

Datatyp

date

Måttenheter
  • dd-mmm-yyyy
Alias
UMLS CUI [1]
C0806020
dd-mmm-yyyy
Stop Time
Beskrivning

End Time

Datatyp

time

Måttenheter
  • 24hr:min
Alias
UMLS CUI [1]
C1522314
24hr:min
Intensity (tick only one)
Beskrivning

Adverse Event: Intensity

Datatyp

integer

Alias
UMLS CUI [1]
C1710066
Relationship to Drug (tick only one)
Beskrivning

Relationship to Drug

Datatyp

integer

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0013230
UMLS CUI [1,3]
C0439849
Action Taken (tick only one)
Beskrivning

Action Taken

Datatyp

integer

Alias
UMLS CUI [1]
C2826626
Corrective Therapy
Beskrivning

If YES, record on Other (non-study) Medications Form.

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Event Course (tick only one)
Beskrivning

Event Course

Datatyp

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0750729
Event Course: If INTERMITTENT; record number of episodes:
Beskrivning

Number of Adverse Events

Datatyp

float

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0449788
Outcome (tick only one)
Beskrivning

Adverse Event Outcome

Datatyp

integer

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Similar models

Adverse Events Ropinirole in Parkinson's Disease GSK 101468/196

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patient Information
C1955348 (UMLS CUI-1)
Patient Number
Item
Patient No.
text
C1830427 (UMLS CUI [1])
Item Group
Adverse Events
C0877248 (UMLS CUI-1)
Adverse Event
Item
Has the patient experienced any new and/or worsening adverse events from the time of Study 196 Completion Visit through the end of the Treatment Period? This CRF will only be used by subjects who have re-enrolled in the study after completion at 36 months. Other subjects (who didn't have to re-enroll) can continus using original CRFs.
boolean
C0877248 (UMLS CUI [1])
Adverse Event Diagnosis
Item
Adverse Event:
text
C0877248 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Seriousness of Adverse Event
Item
Adverse Event: Serious?*
boolean
C1710056 (UMLS CUI [1])
Start Date
Item
Start Date
date
C0808070 (UMLS CUI [1])
Start Time
Item
Start Time
time
C1301880 (UMLS CUI [1])
End Date
Item
Stop Date
date
C0806020 (UMLS CUI [1])
End Time
Item
Stop Time
time
C1522314 (UMLS CUI [1])
Item
Intensity (tick only one)
integer
C1710066 (UMLS CUI [1])
Adverse Event: Intensity
Code List
Intensity (tick only one)
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Item
Relationship to Drug (tick only one)
integer
C1519255 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Relationship to Drug
Code List
Relationship to Drug (tick only one)
CL Item
Not Related (1)
CL Item
Unlikely (2)
CL Item
Suspected (reasonable possibility) (3)
CL Item
Probable (4)
Item
Action Taken (tick only one)
integer
C2826626 (UMLS CUI [1])
Action Taken
Code List
Action Taken (tick only one)
CL Item
None (1)
CL Item
Dose Reduced (2)
CL Item
Dose Increased (3)
CL Item
Drug Interruped/Restarted (4)
CL Item
Drug Stopped (5)
Corrective Therapy
Item
Corrective Therapy
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Item
Event Course (tick only one)
text
C0877248 (UMLS CUI [1,1])
C0750729 (UMLS CUI [1,2])
Event Course
Code List
Event Course (tick only one)
CL Item
Intermittent (1)
CL Item
Constant (2)
Number of Adverse Events
Item
Event Course: If INTERMITTENT; record number of episodes:
float
C1519255 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Item
Outcome (tick only one)
integer
Adverse Event Outcome
Code List
Outcome (tick only one)
CL Item
Resolved (1)
CL Item
Ongoing (2)
CL Item
Resolved with Sequelae (3)
CL Item
Died (4)
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