ID

42598

Beschrijving

Study ID: 101468/201 Clinical Study ID: 101468/201 Study Title: A Single Blind, Parallel Group, Up-titration, Phase 1 Study in Healthy Volunteers to Determine a Starting Dose and Select an Up-titration Regimen for a new Formulation of Ropinirole Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A 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 The Study consists of 21 Visits(Days): Screening (at least 21 days before dosing) Week 1: including Day 1-7 Week 2: including Day 8-14 Week 3: including Day 15-19 Follow-up Visit (7-14 days after last dose) This document contains the Significant Medical/ Surgical History And Physical Examination and the Prior Medication form. It has to be filled in for screening.

Trefwoorden

Versies (4)
  1. 01-09-17 01-09-17 -
  2. 18-06-19 18-06-19 -
  3. 18-06-19 18-06-19 -
  4. 17-09-21 17-09-21 -
Houder van rechten

GlaxoSmithKline

Geüploaded op

17 september 2021

DOI

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Licentie

Creative Commons BY-NC 3.0
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Determination of starting dose and up-titration regimen for a new formulation of Ropinirole in healthy adults, 101468/201

Engels

Significant Medical/ Surgical History And Physical Examination, Prior Medication

1 Formulieren  
Administrative Data
Beschrijving

Administrative Data

Alias
UMLS CUI-1
C1320722
Volunteer panel number
Beschrijving

Volunteer panel number

Datatype

integer

Alias
UMLS CUI [1]
C1300638
Subject number
Beschrijving

Subject number

Datatype

integer

Alias
UMLS CUI [1]
C2348585
Significant Medical/ Surgical History And Physical Examination
Beschrijving

Significant Medical/ Surgical History And Physical Examination

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0031809
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical condition?
Beschrijving

If you tick Yes, fill in the follwoing items for each diagnosis. Only in the absence of a diagnosis, record the signs and symptoms on separate lines.

Datatype

text

Alias
UMLS CUI [1]
C1699700
UMLS CUI [2]
C0543467
Diagnosis
Beschrijving

Diagnosis

Datatype

text

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

Month Year

Datatype

partialDate

Alias
UMLS CUI [1,1]
C0439234
UMLS CUI [1,2]
C0011900
Medical condition
Beschrijving

Medical condition

Datatype

text

Prior Medication
Beschrijving

Prior Medication

Alias
UMLS CUI-1
C2826257
Has the subject taken any medication within 2 weeks prior to the study?
Beschrijving

If you tick ‘Yes’, please record each medication in the following items.

Datatype

text

Alias
UMLS CUI [1]
C2826257
Drug Name
Beschrijving

(Trade name preferred)

Datatype

text

Alias
UMLS CUI [1]
C2360065
Single dose
Beschrijving

(eg 500 mg)

Datatype

text

Alias
UMLS CUI [1]
C1960417
Frequency of this dose
Beschrijving

(eg BID, PRN)

Datatype

text

Alias
UMLS CUI [1]
C3476109
Medication Route
Beschrijving

Other routes may be entered onto the form when appropriate, and will be coded prior to data entry.

Datatype

text

Alias
UMLS CUI [1]
C0013153
Indication of medication
Beschrijving

Indication on Prior Medication page must correlate utilizing the same terminology. Indication on Concomitant page must be recorded on the Adverse Events Page and expressed utilizing the same terminology.

Datatype

text

Alias
UMLS CUI [1,1]
C3146298
UMLS CUI [1,2]
C0013227
Duration of therapy
Beschrijving

(e.g. 6 years)

Datatype

text

Alias
UMLS CUI [1]
C0444921
End date of therapy/medication
Beschrijving

day month year. If therapy/medication is continuing tick the follwing item.

Datatype

date

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0806020
UMLS CUI [2,1]
C0013227
UMLS CUI [2,2]
C0806020
Continuing at end of study?
Beschrijving

If a medication was marked continuing at the initial visit (on the Prior and Concomitant Medication Page), but has since had a dosage change or has been stopped, it must be recorded on this form as a change with the start and end date.

Datatype

text

Alias
UMLS CUI [1]
C1553904
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Similar models

Significant Medical/ Surgical History And Physical Examination, Prior Medication

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Volunteer panel number
Item
Volunteer panel number
integer
C1300638 (UMLS CUI [1])
Subject number
Item
Subject number
integer
C2348585 (UMLS CUI [1])
Item Group
Significant Medical/ Surgical History And Physical Examination
C0262926 (UMLS CUI-1)
C0031809 (UMLS CUI-2)
Item
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical condition?
text
C1699700 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
medical condition; surgery
Code List
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical condition?
CL Item
No (N)
CL Item
Yes (Y)
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Year of diagnosis
Item
Year of first diagnosis
partialDate
C0439234 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Medical condition
text
medical condition
Code List
Medical condition
CL Item
Past (Past)
CL Item
Ongoing (Ongoing)
Item Group
Prior Medication
C2826257 (UMLS CUI-1)
Item
Has the subject taken any medication within 2 weeks prior to the study?
text
C2826257 (UMLS CUI [1])
Prior Medication
Code List
Has the subject taken any medication within 2 weeks prior to the study?
CL Item
No (N)
CL Item
Yes (Y)
Drug Name
Item
Drug Name
text
C2360065 (UMLS CUI [1])
Single dose
Item
Single dose
text
C1960417 (UMLS CUI [1])
Medication frequency
Item
Frequency of this dose
text
C3476109 (UMLS CUI [1])
Item
Medication Route
text
C0013153 (UMLS CUI [1])
Medication Route
Code List
Medication Route
CL Item
intra-articular (IA)
CL Item
intra-arterial (IAR)
CL Item
intra-dermal (ID)
CL Item
inhalation (IH)
CL Item
intra-muscular (IM)
CL Item
intra-thecal (IT)
CL Item
intra-venous (IV)
CL Item
nasal (NA)
CL Item
oral (PO)
CL Item
rectal (PR)
CL Item
subcutaneous (SC)
CL Item
sublingual (SL)
CL Item
transdermal (TD)
CL Item
topical (TO)
CL Item
vaginal (VA)
Indication of medication
Item
Indication of medication
text
C3146298 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Duration of therapy
Item
Duration of therapy
text
C0444921 (UMLS CUI [1])
End date of therapy/medication
Item
End date of therapy/medication
date
C0087111 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
C0013227 (UMLS CUI [2,1])
C0806020 (UMLS CUI [2,2])
Item
Continuing at end of study?
text
C1553904 (UMLS CUI [1])
Continuing therapy
Code List
Continuing at end of study?
CL Item
No (N)
CL Item
Yes (Y)
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