ID

40829

Description

Study ID: 101468/902 Clinical Study ID: 101468/902 Study Title:A study to evaluate the effect of repeated oral doses of ropinirole on cardiac conduction as assessed by 12-lead electrocardiogram compared to placebo and single oral doses of moxifloxacin (Bayer) as a positive control. Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Sponsor: GlaxoSmithKline Phase: Phase 1 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Modutab,ZIPEREVE,ZEPREVE,REPREVE,ADARTREL,REQUIP,Zygara; Zygara,ZIPEREVE,ZEPREVE,Requip Depot,REQUIP,REPREVE,Modutab,ADARTREL Study Indication: Restless Legs Syndrome

Mots-clés

Versions (2)
  1. 19/05/2020 19/05/2020 -
  2. 20/05/2020 20/05/2020 -
Détendeur de droits

GlaxoSmithKline

Téléchargé le

20 mai 2020

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 4.0
Modèle Commentaires :

Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.

Retour au modèle Commentaires
Groupe Item commentaires pour :

Item commentaires pour :

Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.

Effect of ropinirole on cardiac conduction as assessed by 12-lead electrocardiogram (101468/902)

Anglais

Significant Medical/ Surgical History; Physical Examination; Pregnancy Test

1 Formulaires  
Administrative
Description

Administrative

Alias
UMLS CUI-1
C1320722
Subject Number
Description

Subject Number

Type de données

text

Alias
UMLS CUI [1]
C2348585
Visit Date
Description

Visit Date

Type de données

date

Alias
UMLS CUI [1]
C1320303
Significant Medical/ Surgical History (Period 1 Day -1)
Description

Significant Medical/ Surgical History (Period 1 Day -1)

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0489540
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical conditions since screening?
Description

If Yes, List below one diagnosis per line. (Please print clearly) Only in the absence of a diagnosis, record the signs and symptoms on separate lines.

Type de données

boolean

Alias
UMLS CUI [1,1]
C0012634
UMLS CUI [1,2]
C0543467
Significant Medical/ Surgical History (Period 2 Day -1)
Description

Significant Medical/ Surgical History (Period 2 Day -1)

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0489540
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical conditions since treatment period 1?
Description

If Yes, List below one diagnosis per line. (Please print clearly) Only in the absence of a diagnosis, record the signs and symptoms on separate lines.

Type de données

boolean

Alias
UMLS CUI [1,1]
C0012634
UMLS CUI [1,2]
C0543467
Significant Medical/ Surgical History
Description

Significant Medical/ Surgical History

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0489540
Diagnosis
Description

Diagnosis

Type de données

text

Alias
UMLS CUI [1]
C0011900
Year of first diagnosis
Description

Year of first diagnosis

Type de données

partialDate

Alias
UMLS CUI [1,1]
C0439234
UMLS CUI [1,2]
C0011900
Diagnosis status
Description

Diagnosis status

Type de données

integer

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0449438
Physical Examination (Period 1 Day -1)
Description

Physical Examination (Period 1 Day -1)

Alias
UMLS CUI-1
C0031809
Physical Examination - Date
Description

Physical Examination - Date

Type de données

date

Alias
UMLS CUI [1]
C2826643
Physical Examination - Time
Description

Physical Examination - Time

Type de données

time

Alias
UMLS CUI [1]
C2826761
Has there been any change from the last examination (screening)?
Description

If Yes, record below. Any clinically relevant worsening since the last exam must be recorded on the Adverse Events page.

Type de données

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0443172
Physical Examination - Change
Description

Physical Examination - Change

Type de données

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0443172
Physical Examination (Period 2 Day -1)
Description

Physical Examination (Period 2 Day -1)

Alias
UMLS CUI-1
C0031809
Physical Examination - Date
Description

Physical Examination - Date

Type de données

date

Alias
UMLS CUI [1]
C2826643
Physical Examination - Time
Description

Physical Examination - Time

Type de données

time

Alias
UMLS CUI [1]
C2826761
Has there been any change from the last examination (period 1)?
Description

If Yes, record below. Any clinically relevant worsening since the last exam must be recorded on the Adverse Events page.

Type de données

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0443172
Physical Examination - Change
Description

Physical Examination - Change

Type de données

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0443172
Physical Examination (Follow-Up)
Description

Physical Examination (Follow-Up)

Alias
UMLS CUI-1
C0031809
Physical Examination - Date
Description

Physical Examination - Date

Type de données

date

Alias
UMLS CUI [1]
C2826643
Physical Examination - Time
Description

Physical Examination - Time

Type de données

time

Alias
UMLS CUI [1]
C2826761
Has there been any change from the last examination (Period 1 Day -1)?
Description

If Yes, record below. Any clinically relevant worsening since the last exam must be recorded on the Adverse Events page.

Type de données

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0443172
Physical Examination - Change
Description

Physical Examination - Change

Type de données

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0443172
Physical Examination - Investigator's Signature
Description

Physical Examination - Investigator's Signature

Alias
UMLS CUI-1
C0031809
UMLS CUI-2
C2346576
Investigator's Signature
Description

Investigator's Signature

Type de données

text

Alias
UMLS CUI [1]
C2346576
Investigator's Signature Date
Description

Investigator's Signature Date

Type de données

date

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C0011008
Pregnancy Test (Females only)
Description

Pregnancy Test (Females only)

Alias
UMLS CUI-1
C0032976
Was a pregnancy test carried out?
Description

Was a pregnancy test carried out?

Type de données

boolean

Alias
UMLS CUI [1]
C0032976
If no pregnancy test has been carried out, please specify reason
Description

If no pregnancy test has been carried out, please specify reason

Type de données

text

Alias
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C2826287
Date and time of pregnancy test
Description

Date and time of pregnancy test

Type de données

datetime

Alias
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C0040223
Result of pregnancy test
Description

If ’Positive’, withdraw the subject from the study.

Type de données

integer

Alias
UMLS CUI [1]
C0427777
Please mark box for test type
Description

Please mark box for test type

Type de données

integer

Alias
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C0332307
If other test type, specify
Description

If other test type, specify

Type de données

text

Alias
UMLS CUI [1,1]
C0032976
UMLS CUI [1,2]
C0332307
UMLS CUI [1,3]
C0205394
UMLS CUI [1,4]
C2348235
Laboratory name, if applicable
Description

ensure result is included on laboratory report

Type de données

text

Alias
UMLS CUI [1]
C1882331
Retour au début de la page

Similar models

Significant Medical/ Surgical History; Physical Examination; Pregnancy Test

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Administrative
C1320722 (UMLS CUI-1)
Subject Number
Item
Subject Number
text
C2348585 (UMLS CUI [1])
Visit Date
Item
Visit Date
date
C1320303 (UMLS CUI [1])
Item Group
Significant Medical/ Surgical History (Period 1 Day -1)
C0262926 (UMLS CUI-1)
C0489540 (UMLS CUI-2)
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical conditions since screening?
Item
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical conditions since screening?
boolean
C0012634 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Item Group
Significant Medical/ Surgical History (Period 2 Day -1)
C0262926 (UMLS CUI-1)
C0489540 (UMLS CUI-2)
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical conditions since treatment period 1?
Item
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical conditions since treatment period 1?
boolean
C0012634 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Item Group
Significant Medical/ Surgical History
C0262926 (UMLS CUI-1)
C0489540 (UMLS CUI-2)
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Year of first diagnosis
Item
Year of first diagnosis
partialDate
C0439234 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Diagnosis status
integer
C0011900 (UMLS CUI [1,1])
C0449438 (UMLS CUI [1,2])
Diagnosis status
Code List
Diagnosis status
CL Item
Past (1)
CL Item
Ongoing (2)
Item Group
Physical Examination (Period 1 Day -1)
C0031809 (UMLS CUI-1)
Physical Examination - Date
Item
Physical Examination - Date
date
C2826643 (UMLS CUI [1])
Physical Examination - Time
Item
Physical Examination - Time
time
C2826761 (UMLS CUI [1])
Has there been any change from the last examination (screening)?
Item
Has there been any change from the last examination (screening)?
boolean
C0031809 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Physical Examination - Change
Item
Physical Examination - Change
text
C0031809 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Item Group
Physical Examination (Period 2 Day -1)
C0031809 (UMLS CUI-1)
Physical Examination - Date
Item
Physical Examination - Date
date
C2826643 (UMLS CUI [1])
Physical Examination - Time
Item
Physical Examination - Time
time
C2826761 (UMLS CUI [1])
Has there been any change from the last examination (period 1)?
Item
Has there been any change from the last examination (period 1)?
boolean
C0031809 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Physical Examination - Change
Item
Physical Examination - Change
text
C0031809 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Item Group
Physical Examination (Follow-Up)
C0031809 (UMLS CUI-1)
Physical Examination - Date
Item
Physical Examination - Date
date
C2826643 (UMLS CUI [1])
Physical Examination - Time
Item
Physical Examination - Time
time
C2826761 (UMLS CUI [1])
Has there been any change from the last examination (Period 1 Day -1)?
Item
Has there been any change from the last examination (Period 1 Day -1)?
boolean
C0031809 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Physical Examination - Change
Item
Physical Examination - Change
text
C0031809 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Item Group
Physical Examination - Investigator's Signature
C0031809 (UMLS CUI-1)
C2346576 (UMLS CUI-2)
Investigator's Signature
Item
Investigator's Signature
text
C2346576 (UMLS CUI [1])
Investigator's Signature Date
Item
Investigator's Signature Date
date
C1519316 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item Group
Pregnancy Test (Females only)
C0032976 (UMLS CUI-1)
Was a pregnancy test carried out?
Item
Was a pregnancy test carried out?
boolean
C0032976 (UMLS CUI [1])
If no pregnancy test has been carried out, please specify reason
Item
If no pregnancy test has been carried out, please specify reason
text
C0032976 (UMLS CUI [1,1])
C2826287 (UMLS CUI [1,2])
Date and time of pregnancy test
Item
Date and time of pregnancy test
datetime
C0032976 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,3])
Item
Result of pregnancy test
integer
C0427777 (UMLS CUI [1])
Result of pregnancy test
Code List
Result of pregnancy test
CL Item
Positive (1)
CL Item
Negative (2)
Item
Please mark box for test type
integer
C0032976 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Please mark box for test type
Code List
Please mark box for test type
CL Item
Dipstick urine HCG (1)
CL Item
Serum HCG (2)
CL Item
Other, please specify (3)
If other test type, specify
Item
If other test type, specify
text
C0032976 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
Laboratory name, if applicable
Item
Laboratory name, if applicable
text
C1882331 (UMLS CUI [1])
Retour au début de la page 

Contact

Utilisez ce formulaire pour les retours, les questions et les améliorations suggérées.

Les champs marqués d’un * sont obligatoires.

Aide

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial