Inglés

4 Week control visit (V2)

1 formularios  
Date of Visit
Descripción

Date of Visit

Alias
UMLS CUI-1
C2097637
Date of visit
Descripción

Date of visit

Tipo de datos

date

Alias
UMLS CUI [1]
C1320303
Recent Medical history
Descripción

Recent Medical history

Alias
UMLS CUI-1
C0262926
Changes in relevant medical history since screening visit
Descripción

relevant medical history

Tipo de datos

integer

Alias
UMLS CUI [1]
C0262926
Are there any adverse events since last visit?
Descripción

If yes, please fill in AE FORM.

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0877248
Changes in MSA History since last visit (V1)
Descripción

Changes in MSA History since Screening visit (V0)

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0393571
UMLS CUI [1,2]
C1457887
Syncope
Descripción

MSA syncope

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0393571
UMLS CUI [1,2]
C0039070
Orthostatic hypotension
Descripción

MSA Orthostatic hypotension

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0393571
UMLS CUI [1,2]
C0020651
Urinary Incontinence
Descripción

MSA Urinary Incontinence

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0393571
UMLS CUI [1,2]
C0042024
Erectile Dysfuntion
Descripción

MSA Erectile Dysfuntion

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0393571
UMLS CUI [1,2]
C2733447
Other (please specify)
Descripción

MSA Other autonomic symptoms

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0393571
UMLS CUI [1,2]
C2674101
UMLS CUI [1,3]
C1521902
Bradykinesia
Descripción

MSA Bradykinesia

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2733447
UMLS CUI [1,2]
C3176307
Rigidity
Descripción

MSA Rigidity

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2733447
UMLS CUI [1,2]
C0858572
Tremor
Descripción

MSA Tremor

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2733447
UMLS CUI [1,2]
C0040822
Resting tremor
Descripción

Only answer, if answer to previous question was 'yes'.

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0234379
Postural tremor
Descripción

Only answer, if answer to previous question was 'yes'.

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0234378
other (please specify)
Descripción

MSA Other parkinsonism symptoms

Tipo de datos

text

Alias
UMLS CUI [1,1]
C2733447
UMLS CUI [1,2]
C1457887
UMLS CUI [1,3]
C1521902
Gait ataxia
Descripción

MSA Gait ataxia

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2732311
UMLS CUI [1,2]
C0751837
Limb ataxia
Descripción

MSA limb ataxia

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2732311
UMLS CUI [1,2]
C4015302
Other (please specify)
Descripción

MSA Other cerebellar symptoms

Tipo de datos

text

Alias
UMLS CUI [1,1]
C2732311
UMLS CUI [1,2]
C0037088
UMLS CUI [1,3]
C1521902
Current frequency of falls
Descripción

since last visit

Tipo de datos

integer

Alias
UMLS CUI [1]
C1285588
Concomitant medication
Descripción

Concomitant medication

Alias
UMLS CUI-1
C2347852
Does the patient take any concomitant medication?
Descripción

If Yes, please fill in Concomitant Medication Record.

Tipo de datos

boolean

Alias
UMLS CUI [1]
C2347852
Has the patient a stable regimen for at least one month for drugs acting against Parkinsonism.
Descripción

If no, exclusion of the patient.

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0003405
Has the patient a stable regimen for at least one month for drugs acting against autonomic dysfunction.
Descripción

If no, exclusion of the patient.

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C3277919
Has the patient a stable regimen for at least one month for antidepressant and antidementive drugs.
Descripción

If no, exclusion of the patient.

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0003289
UMLS CUI [1,3]
C0497327
Vital signs
Descripción

Vital signs

Alias
UMLS CUI-1
C0031809
Systolic Blood Pressure
Descripción

Systolic Blood Pressure

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
UMLS CUI [1]
C0871470
mmHg
Diastolic blood pressure
Descripción

Diastolic blood pressure

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
UMLS CUI [1]
C0428883
mmHg
Heart rate
Descripción

Heart rate

Tipo de datos

integer

Unidades de medida
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
Temperature
Descripción

Body Temperature

Tipo de datos

integer

Unidades de medida
  • °C
Alias
UMLS CUI [1]
C0005903
°C
Physical examination
Descripción

Physical examination

Alias
UMLS CUI-1
C0031809
General physical examination
Descripción

General physical examination

Tipo de datos

integer

Alias
UMLS CUI [1]
C0031809
Physical examination
Descripción

Physical examination

Alias
UMLS CUI-1
C0031809
Code
Descripción

pHysical examination code

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0805701
Finding
Descripción

physical examination finding

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0243095
Neurological examination
Descripción

Neurological examination

Alias
UMLS CUI-1
C0027853
Cranial nerves
Descripción

Neurologic examination cranial nerves

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0558819
If abnormal, specify
Descripción

cranial nerves examination specify

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0558819
UMLS CUI [1,3]
C1521902
Motor function
Descripción

Neurologic examination Motor function

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0234130
If abnormal, specify
Descripción

Motor function specify

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0234130
UMLS CUI [1,3]
C1521902
Reflexes
Descripción

Neurologic examination Reflexes

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0436145
If abnormal, specify
Descripción

Reflexes specify

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0436145
UMLS CUI [1,3]
C1521902
Coordination
Descripción

Neurologic examination coordination

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0242414
If abnormal, specify
Descripción

Coordination specify

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0242414
UMLS CUI [1,3]
C1521902
Sensation
Descripción

Neurologic examination sensation

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0036658
If abnormal, specify
Descripción

Sensation specify

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0036658
UMLS CUI [1,3]
C1521902
Laboratory test
Descripción

Laboratory test

Alias
UMLS CUI-1
C0022885
Date
Descripción

d laboratory! Please fill in the raised values and assess whether they´re normal or not. If abnormal, evaluate if it is clinically significant or not. If the value is abnormal and clinically significant, please document as concomitant disease under medical history.

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0022885
Laboratory test performed?
Descripción

laboratory procedures

Tipo de datos

text

Alias
UMLS CUI [1]
C0022885
Laboratory test
Descripción

Laboratory test

Alias
UMLS CUI-1
C0022885
Type of laboratory procedure
Descripción

Type of laboratory procedure

Tipo de datos

integer

Alias
UMLS CUI [1]
C0022885
Value
Descripción

Laboratory procedure value

Tipo de datos

float

Alias
UMLS CUI [1,1]
C0587081
UMLS CUI [1,2]
C0587081
Normal
Descripción

Laboratory result normal

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0587081
UMLS CUI [1,2]
C0459422
Clinical significant
Descripción

Laboratory finding significant

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0456984
UMLS CUI [1,2]
C0750502
Clinically not significant
Descripción

Laboratory finding not significant

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0587081
UMLS CUI [1,2]
C2985739
Not done
Descripción

Laboratory test not done

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0445106
Study medication
Descripción

Study medication

Alias
UMLS CUI-1
C0013227
UMLS CUI-2
C0304229
Did any study-drug side effects occur?
Descripción

If yes, please fill out AE form!

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0304229
UMLS CUI [1,2]
C0041755
Did the patient regularly take the study-drug?
Descripción

regular intake of study medication

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0304229
UMLS CUI [1,3]
C0205272
If no, please explain:
Descripción

Study medication intake

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0304229
UMLS CUI [1,3]
C0205272
Number of capsules returned
Descripción

Number of capsules returned

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C2699071
UMLS CUI [1,2]
C0039225
Comment (in case of missing capsules)
Descripción

Missing capsules

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1705492
UMLS CUI [1,2]
C0178602
Trial medication exchange
Descripción

Trial medication exchange

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C3854006
UMLS CUI [1,2]
C3469597
Date
Descripción

Date of study drug exchange

Tipo de datos

date

Alias
UMLS CUI [1,1]
C3854006
UMLS CUI [1,2]
C3469597
UMLS CUI [1,3]
C0011008
Number of Capsules dispensed
Descripción

Capsules (EGCG 400mg or Placebo) Regimen 1-0-1 Total dose 800mg/d

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0805077
Planned new dosis start
Descripción

Planned medication start

Tipo de datos

date

Alias
UMLS CUI [1,1]
C1521826
UMLS CUI [1,2]
C0808070
Signature of investigator
Descripción

Signature of investigator

Alias
UMLS CUI-1
C2346576
Date of Investigator Signature
Descripción

Investigator Signature Date

Tipo de datos

date

Alias
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
Name of investigator
Descripción

Investigator name

Tipo de datos

text

Alias
UMLS CUI [1]
C2826892
Investigator signature
Descripción

I confirm the correctness of the data documented above.

Tipo de datos

text

Alias
UMLS CUI [1]
C2346576
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Similar models

4 Week control visit (V2)

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Date of Visit
C2097637 (UMLS CUI-1)
Date of visit
Item
Date of visit
date
C1320303 (UMLS CUI [1])
Item Group
Recent Medical history
C0262926 (UMLS CUI-1)
Item
Changes in relevant medical history since screening visit
integer
C0262926 (UMLS CUI [1])
relevant medical history
Code List
Changes in relevant medical history since screening visit
CL Item
Yes (please specify below) (1)
CL Item
No (2)
adverse event
Item
Are there any adverse events since last visit?
boolean
C0877248 (UMLS CUI [1])
Changes in MSA History since Screening visit (V0)
Item
Changes in MSA History since last visit (V1)
boolean
C0393571 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
MSA syncope
Item
Syncope
boolean
C0393571 (UMLS CUI [1,1])
C0039070 (UMLS CUI [1,2])
MSA Orthostatic hypotension
Item
Orthostatic hypotension
boolean
C0393571 (UMLS CUI [1,1])
C0020651 (UMLS CUI [1,2])
MSA Urinary Incontinence
Item
Urinary Incontinence
boolean
C0393571 (UMLS CUI [1,1])
C0042024 (UMLS CUI [1,2])
MSA Erectile Dysfuntion
Item
Erectile Dysfuntion
boolean
C0393571 (UMLS CUI [1,1])
C2733447 (UMLS CUI [1,2])
MSA Other autonomic symptoms
Item
Other (please specify)
text
C0393571 (UMLS CUI [1,1])
C2674101 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
MSA Bradykinesia
Item
Bradykinesia
boolean
C2733447 (UMLS CUI [1,1])
C3176307 (UMLS CUI [1,2])
MSA Rigidity
Item
Rigidity
boolean
C2733447 (UMLS CUI [1,1])
C0858572 (UMLS CUI [1,2])
MSA Tremor
Item
Tremor
boolean
C2733447 (UMLS CUI [1,1])
C0040822 (UMLS CUI [1,2])
Resting tremor
Item
Resting tremor
boolean
C0234379 (UMLS CUI [1])
Postural tremor
Item
Postural tremor
boolean
C0234378 (UMLS CUI [1])
MSA Other parkinsonism symptoms
Item
other (please specify)
text
C2733447 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
MSA Gait ataxia
Item
Gait ataxia
boolean
C2732311 (UMLS CUI [1,1])
C0751837 (UMLS CUI [1,2])
MSA limb ataxia
Item
Limb ataxia
boolean
C2732311 (UMLS CUI [1,1])
C4015302 (UMLS CUI [1,2])
MSA Other cerebellar symptoms
Item
Other (please specify)
text
C2732311 (UMLS CUI [1,1])
C0037088 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item
Current frequency of falls
integer
C1285588 (UMLS CUI [1])
frequency of falls
Code List
Current frequency of falls
CL Item
several times per day (1)
CL Item
several times per week (2)
CL Item
several times per month (3)
CL Item
several times per year (4)
Item Group
Concomitant medication
C2347852 (UMLS CUI-1)
Concomitant Medication
Item
Does the patient take any concomitant medication?
boolean
C2347852 (UMLS CUI [1])
Parkinson drugs
Item
Has the patient a stable regimen for at least one month for drugs acting against Parkinsonism.
boolean
C0003405 (UMLS CUI [1])
pharmaceutical preparation autonomic dysfunction
Item
Has the patient a stable regimen for at least one month for drugs acting against autonomic dysfunction.
boolean
C0013227 (UMLS CUI [1,1])
C3277919 (UMLS CUI [1,2])
antidepressant and antidementive drugs
Item
Has the patient a stable regimen for at least one month for antidepressant and antidementive drugs.
boolean
C0013227 (UMLS CUI [1,1])
C0003289 (UMLS CUI [1,2])
C0497327 (UMLS CUI [1,3])
Item Group
Vital signs
C0031809 (UMLS CUI-1)
Systolic Blood Pressure
Item
Systolic Blood Pressure
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
Diastolic blood pressure
integer
C0428883 (UMLS CUI [1])
Heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Body Temperature
Item
Temperature
integer
C0005903 (UMLS CUI [1])
Item Group
Physical examination
C0031809 (UMLS CUI-1)
Item
integer
C0031809 (UMLS CUI [1])
General physical examination
Code List
General physical examination
CL Item
normal (1)
CL Item
abnormal (please specify below) (2)
Item Group
Physical examination
C0031809 (UMLS CUI-1)
Item
Code
integer
C0031809 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
pHysical examination code
Code List
Code
CL Item
Cardiovascular (01)
CL Item
Pulmonary (02)
CL Item
Abdominal (03)
CL Item
Genitourinary (04)
CL Item
Skeletal/Muscular (05)
CL Item
Psychiatric (06)
CL Item
other (07)
physical examination finding
Item
Finding
text
C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Item Group
Neurological examination
C0027853 (UMLS CUI-1)
Item
Cranial nerves
integer
C0027853 (UMLS CUI [1,1])
C0558819 (UMLS CUI [1,2])
Neurologic examination cranial nerves
Code List
Cranial nerves
CL Item
normal (1)
CL Item
abnormal (2)
cranial nerves examination specify
Item
If abnormal, specify
text
C0027853 (UMLS CUI [1,1])
C0558819 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item
Motor function
integer
C0027853 (UMLS CUI [1,1])
C0234130 (UMLS CUI [1,2])
Neurologic examination Motor function
Code List
Motor function
CL Item
normal (1)
CL Item
abnormal (2)
Motor function specify
Item
If abnormal, specify
text
C0027853 (UMLS CUI [1,1])
C0234130 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item
Reflexes
integer
C0027853 (UMLS CUI [1,1])
C0436145 (UMLS CUI [1,2])
Neurologic examination Reflexes
Code List
Reflexes
CL Item
normal (1)
CL Item
abnormal (2)
Reflexes specify
Item
If abnormal, specify
text
C0027853 (UMLS CUI [1,1])
C0436145 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item
Coordination
integer
C0027853 (UMLS CUI [1,1])
C0242414 (UMLS CUI [1,2])
Neurologic examination coordination
Code List
Coordination
CL Item
normal (1)
CL Item
abnormal (2)
Coordination specify
Item
If abnormal, specify
text
C0027853 (UMLS CUI [1,1])
C0242414 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item
Sensation
integer
C0027853 (UMLS CUI [1,1])
C0036658 (UMLS CUI [1,2])
Neurologic examination sensation
Code List
Sensation
CL Item
normal (1)
CL Item
abnormal (2)
Sensation specify
Item
If abnormal, specify
text
C0027853 (UMLS CUI [1,1])
C0036658 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item Group
Laboratory test
C0022885 (UMLS CUI-1)
Date laboratory
Item
Date
date
C0011008 (UMLS CUI [1,1])
C0022885 (UMLS CUI [1,2])
Item
Laboratory test performed?
text
C0022885 (UMLS CUI [1])
laboratory procedures
Code List
Laboratory test performed?
CL Item
done (1)
CL Item
not done (2)
Item Group
Laboratory test
C0022885 (UMLS CUI-1)
Item
Type of laboratory procedure
integer
C0022885 (UMLS CUI [1])
Type of laboratory procedure
Code List
Type of laboratory procedure
CL Item
Erythrocytes T/L (1)
CL Item
Leukocytes G/L (2)
CL Item
Thrombocytes G/L (3)
CL Item
Hemoglobin g/dL (4)
CL Item
PTT sec (5)
CL Item
PchE kU/L (6)
CL Item
GOT (AST) U/L (7)
CL Item
GPT (ALT) U/L (8)
CL Item
Bilirubin mg/dL (9)
CL Item
Creatinine mg/dL (10)
CL Item
Creatine Kinase U/L (11)
CL Item
Potassium mmol/L (12)
CL Item
Sodium mmol/L (13)
CL Item
GFR mL/min (14)
CL Item
Iron ug/dL (15)
CL Item
Ferritin ng/mL (16)
CL Item
Transferrin g/dL (17)
CL Item
Albumine g/dL (18)
CL Item
Total protein g/dL (19)
Laboratory procedure value
Item
Value
float
C0587081 (UMLS CUI [1,1])
C0587081 (UMLS CUI [1,2])
Laboratory result normal
Item
Normal
boolean
C0587081 (UMLS CUI [1,1])
C0459422 (UMLS CUI [1,2])
Laboratory finding significant
Item
Clinical significant
boolean
C0456984 (UMLS CUI [1,1])
C0750502 (UMLS CUI [1,2])
Laboratory finding not significant
Item
Clinically not significant
boolean
C0587081 (UMLS CUI [1,1])
C2985739 (UMLS CUI [1,2])
Laboratory test not done
Item
Not done
boolean
C0022885 (UMLS CUI [1,1])
C0445106 (UMLS CUI [1,2])
Item Group
Study medication
C0013227 (UMLS CUI-1)
C0304229 (UMLS CUI-2)
side effects study drug
Item
Did any study-drug side effects occur?
boolean
C0304229 (UMLS CUI [1,1])
C0041755 (UMLS CUI [1,2])
regular intake of study medication
Item
Did the patient regularly take the study-drug?
boolean
C0013227 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
C0205272 (UMLS CUI [1,3])
Study medication intake
Item
If no, please explain:
text
C0013227 (UMLS CUI [1,1])
C0304229 (UMLS CUI [1,2])
C0205272 (UMLS CUI [1,3])
Number of capsules returned
Item
Number of capsules returned
integer
C2699071 (UMLS CUI [1,1])
C0039225 (UMLS CUI [1,2])
Missing capsules
Item
Comment (in case of missing capsules)
text
C1705492 (UMLS CUI [1,1])
C0178602 (UMLS CUI [1,2])
Item
Trial medication exchange
integer
C3854006 (UMLS CUI [1,1])
C3469597 (UMLS CUI [1,2])
Trial medication distribution
Code List
Trial medication exchange
CL Item
done  (1)
CL Item
not done (2)
Date of study drug exchange
Item
Date
date
C3854006 (UMLS CUI [1,1])
C3469597 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Number of Capsules dispensed
Item
Number of Capsules dispensed
integer
C0013227 (UMLS CUI [1,1])
C0805077 (UMLS CUI [1,2])
Planned medication start
Item
Planned new dosis start
date
C1521826 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Item Group
Signature of investigator
C2346576 (UMLS CUI-1)
Investigator Signature Date
Item
Date of Investigator Signature
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator name
Item
Name of investigator
text
C2826892 (UMLS CUI [1])
Investigator signature
Item
Investigator signature
text
C2346576 (UMLS CUI [1])
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