Englisch

Patient Continuation Withdrawal GSK Ropinirole in Patients Suffering from Restless Legs Syndrome 101468/190

1 Formulare  
PATIENT CONTINUATION/WITHDRAWAL
Beschreibung

PATIENT CONTINUATION/WITHDRAWAL

Alias
UMLS CUI-1
C2348568
Is the patient continuing in the study?
Beschreibung

Is the patient continuing in the study?

Datentyp

integer

Alias
UMLS CUI [1]
C2348568
Is the patient continuing in the study?
Beschreibung

Is the patient continuing in the study?

Datentyp

integer

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C0392360
Is the patient continuing in the study? Please specify:
Beschreibung

Is the patient continuing in the study?

Datentyp

text

Alias
UMLS CUI [1,1]
C2348568
UMLS CUI [1,2]
C0392360
UMLS CUI [1,3]
C0205394
INVESTIGATOR SIGNATURE
Beschreibung

INVESTIGATOR SIGNATURE

Alias
UMLS CUI-1
C2346576
Investigator’s Signature
Beschreibung

Investigator’s Signature

Datentyp

text

Alias
UMLS CUI [1]
C2346576
Date
Beschreibung

Date

Datentyp

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Zum Seitenanfang zurückkehren

Ähnliche Modelle

Patient Continuation Withdrawal GSK Ropinirole in Patients Suffering from Restless Legs Syndrome 101468/190

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
PATIENT CONTINUATION/WITHDRAWAL
C2348568 (UMLS CUI-1)
Item
Is the patient continuing in the study?
integer
C2348568 (UMLS CUI [1])
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’, please mark the primary cause of withdrawal. (Mark one box only). (2)
Item
Is the patient continuing in the study?
integer
C2348568 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Is the patient continuing in the study?
Code List
Is the patient continuing in the study?
CL Item
Baseline sign and symptom (please complete Baseline Signs and Symptoms page) (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)
Is the patient continuing in the study?
Item
Is the patient continuing in the study? Please specify:
text
C2348568 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item Group
INVESTIGATOR SIGNATURE
C2346576 (UMLS CUI-1)
Investigator’s Signature
Item
Investigator’s Signature
text
C2346576 (UMLS CUI [1])
Date
Item
Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Zum Seitenanfang zurückkehren