ID

42817

Beskrivning

Ropinirole Case Report Form GSK RRL100013 GSK Study ID: 100013 Clinical Study ID: RRL100013 A 12-Week, Double-Blind, Placebo-Controlled, Twice-Daily Dosing Study to Assess the Efficacy and Safety of Ropinirole in Patients Suffering from Restless Legs Syndrome (RLS) Requiring Extended Treatment Coverage

Nyckelord

Versioner (4)
  1. 2018-02-22 2018-02-22 -
  2. 2018-02-24 2018-02-24 -
  3. 2018-02-25 2018-02-25 -
  4. 2021-09-17 2021-09-17 -
Rättsinnehavare

gsk

Uppladdad den

17 september 2021

DOI

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Licens

Creative Commons BY-NC 3.0
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Ropinirole Case Report Form GSK RRL100013

Engelsk

PREGNANCY INFORMATION

4 Formulär  
PREGNANCY INFORMATION
Beskrivning

PREGNANCY INFORMATION

MONITOR DATA VALIDATION CHECK
Beskrivning

Check that responses provided correspond with the sex of the subject. If the answer to the subject pregnancy question is 'Yes', ensure that a Pregnancy Notification Form has been completed for the subject. If the answer to the female partner of the male subject pregnancy question is 'Yes', ensure that a Pregnancy Notification Form has been completed for the subject's partner.

Datatyp

text

Alias
UMLS CUI [1,1]
C1519941
UMLS CUI [1,2]
C0030695
STUDY CONCLUSION INVESTIGATOR INSTRUCTIONS
Beskrivning

Refer to protocol section(s) 9 to evaluate subject completion or withdrawal from the study. If subject completed study "Date of subject completion or withdrawal" must match the last scheduled study visit date. If subject withdrew and a withdrawal visit was conducted: "Date of subject completion or withdrawal" must match the date of subject withdrawal. If subject lost to follow-up: "Date of subject completion or withdrawal" must match the last actual contact with the subject whether or not the contact was a clinic visit. Do not record dates of unsuccessful attempts to contact the subject. Note: An 'actual contact' is defined as an interaction between the subject and the investigator or investigator's designee, where the investigatorldesignee has the opportunity to query the subject about the subject's status. This would include clinic visits and telephone contacts, but normally would not include mail correspondence or third party reports.

Datatyp

integer

Alias
UMLS CUI [1,1]
C1707478
UMLS CUI [1,2]
C0008972
UMLS CUI [1,3]
C1442085
PREGNANCY INFORMATION
Beskrivning

PREGNANCY INFORMATION

Pregnancy Information
Beskrivning

Pregnancy Information

Alias
UMLS CUI-1
C0032961
UMLS CUI-2
C1533716
Did the subject become pregnant during the study? (mark one box below)
Beskrivning

If 'Yes' record details on Pregnancy Notification Form.

Datatyp

text

Alias
UMLS CUI [1]
C3828490
Did the female partner of a male patient become pregnant during the study? (mark one box below)
Beskrivning

If 'Yes' record details on Pregnancy Notification Form.

Datatyp

text

Alias
UMLS CUI [1,1]
C0919624
UMLS CUI [1,2]
C0347984
UMLS CUI [1,3]
C0008972
Study Conclusion
Beskrivning

Study Conclusion

Alias
UMLS CUI-1
C1707478
UMLS CUI-2
C0008976
UMLS CUI-3
C0042210
John Hopkins RLS Quality of Life questionnaire
Beskrivning

John Hopkins RLS Quality of Life questionnaire

Datatyp

text

Alias
UMLS CUI [1,1]
C0034394
UMLS CUI [1,2]
C0034380
UMLS CUI [1,3]
C0679830
UMLS CUI [1,4]
C0035258
MEDICAL OUTCOMES STUDY SLEEP SCALE
Beskrivning

MEDICAL OUTCOMES STUDY SLEEP SCALE

Datatyp

integer

Alias
UMLS CUI [1,1]
C0449820
UMLS CUI [1,2]
C0037313
Profile of mood states
Beskrivning

Profile of mood states

Datatyp

text

Alias
UMLS CUI [1]
C0451394
Hospital anxiety and depression scale
Beskrivning

Hospital anxiety and depression scale

Datatyp

text

Alias
UMLS CUI [1]
C3539657
Pittsburgh Sleep quality index
Beskrivning

Pittsburgh Sleep quality index

Datatyp

text

Alias
UMLS CUI [1]
C0424563
Patient global improvement scale
Beskrivning

Patient global improvement scale

Datatyp

text

Alias
UMLS CUI [1]
C0451125
PATIENT SATISFACTION QUESTION
Beskrivning

PATIENT SATISFACTION QUESTION

Datatyp

text

Alias
UMLS CUI [1]
C3476649
Did the subject experience any Serious Adverse Event during the study period ?
Beskrivning

Serious Adverse Event

Datatyp

boolean

Alias
UMLS CUI [1]
C1519255
Total number of SAE's:
Beskrivning

If yes, please give the total number of SAE's:

Datatyp

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C1519255
Did any elimination criteria become applicable during the study?
Beskrivning

elimination criteria

Datatyp

boolean

Alias
UMLS CUI [1]
C0680251
Did any elimination criteria become applicable during the study? If Yes, please specify
Beskrivning

elimination criteria

Datatyp

text

Alias
UMLS CUI [1]
C0680251
Was the subject withdrawn from study?
Beskrivning

withdrawn

Datatyp

boolean

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C0008976
Please tick the ONE most appropriate category for drop out
Beskrivning

If Yes, please specify

Datatyp

integer

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C0392360
UMLS CUI [1,3]
C0008976
SAE Number
Beskrivning

If Serious adverse event, please specify

Datatyp

integer

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0237753
AE Number or Code
Beskrivning

If Non-serious adverse event, please specify

Datatyp

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0237753
If Protocol violation, please specify
Beskrivning

Protocol violation

Datatyp

text

Alias
UMLS CUI [1]
C1709750
Other reason for withdrawal
Beskrivning

If Other, please specify

Datatyp

text

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C0392360
UMLS CUI [1,3]
C0008976
reason for withdrawal, Who made the decision?
Beskrivning

reason for withdrawal

Datatyp

integer

Alias
UMLS CUI [1,1]
C2349954
UMLS CUI [1,2]
C0392360
UMLS CUI [1,3]
C0008976
Date of last contact
Beskrivning

Date of last contact

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1705415
Was the subject in good condition at date of last contact?
Beskrivning

subject condition

Datatyp

integer

Alias
UMLS CUI [1,1]
C1142435
UMLS CUI [1,2]
C0681850
Investigators signature
Beskrivning

Investigators signature

Datatyp

text

Alias
UMLS CUI [1]
C2346576
Investigators signature Date
Beskrivning

Investigators signature Date

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C2346576
RLS Symptoms on the first day of the patient
Beskrivning

RLS Symptoms on the first day of the patient

Alias
UMLS CUI-1
C1457887
UMLS CUI-2
C0035258
Date
Beskrivning

From 07:00 on the morning to 06:59 of the next morning.

Datatyp

date

Alias
UMLS CUI [1]
C0011008
1. Did you take your study medication during the period listed above?
Beskrivning

medication

Datatyp

boolean

Alias
UMLS CUI [1]
C0013227
If Yes, what time:
Beskrivning

time medication intake

Datatyp

time

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C1512806
2. Did you experience any RLS symptoms during the period listed above?
Beskrivning

Symptoms RLS

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0035258
3. What was the first time your RLS symptoms began?
Beskrivning

time

Datatyp

time

Alias
UMLS CUI [1]
C0040223
4. What time did you fall asleep?
Beskrivning

time fall sleep

Datatyp

time

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C3830397
5. What time did you wake up the following morning?
Beskrivning

time wake up

Datatyp

time

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C1170730
6. Which parts of your body were affected by RLS symptoms during the period listed above?
Beskrivning

site

Datatyp

integer

Alias
UMLS CUI [1]
C1515974
7. Did you have RLS symptoms in this time frame?- 7 a.m. to 11:59 a.m.
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 12 p.m. to 2:59 p.m.Noon
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 3 p.m. to 5:59 p.m.
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 6 p.m. to 8:59 p.m.
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 9 p.m. to 11:59 p.m.
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 12 a.m. to 6:59 a.m. Midnight
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
RLS Symptoms on the first day of the patient
Beskrivning

RLS Symptoms on the first day of the patient

Alias
UMLS CUI-1
C1457887
UMLS CUI-2
C0035258
Date
Beskrivning

From 07:00 on the morning to 06:59 of the next morning.

Datatyp

date

Alias
UMLS CUI [1]
C0011008
1. Did you take your study medication during the period listed above?
Beskrivning

medication

Datatyp

boolean

Alias
UMLS CUI [1]
C0013227
If Yes, what time:
Beskrivning

time medication intake

Datatyp

time

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C1512806
2. Did you experience any RLS symptoms during the period listed above?
Beskrivning

Symptoms RLS

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0035258
3. What was the first time your RLS symptoms began?
Beskrivning

time

Datatyp

time

Alias
UMLS CUI [1]
C0040223
4. What time did you fall asleep?
Beskrivning

time fall sleep

Datatyp

time

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C3830397
5. What time did you wake up the following morning?
Beskrivning

time wake up

Datatyp

time

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C1170730
6. Which parts of your body were affected by RLS symptoms during the period listed above?
Beskrivning

site

Datatyp

integer

Alias
UMLS CUI [1]
C1515974
7. Did you have RLS symptoms in this time frame?- 7 a.m. to 11:59 a.m.
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 12 p.m. to 2:59 p.m.Noon
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 3 p.m. to 5:59 p.m.
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 6 p.m. to 8:59 p.m.
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 9 p.m. to 11:59 p.m.
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
7. Did you have RLS symptoms in this time frame?- 12 a.m. to 6:59 a.m. Midnight
Beskrivning

time frame

Datatyp

boolean

Alias
UMLS CUI [1]
C0332168
8. What was the maximum severity of your RLS symptoms during this time frame?
Beskrivning

symptom severity

Datatyp

text

Alias
UMLS CUI [1]
C1319166
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
Beskrivning

symptom Beginning

Datatyp

integer

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0439659
Tillbaka till toppen

Similar models

PREGNANCY INFORMATION

4 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
PREGNANCY INFORMATION
MONITOR DATA VALIDATION CHECK
Item
MONITOR DATA VALIDATION CHECK
text
C1519941 (UMLS CUI [1,1])
C0030695 (UMLS CUI [1,2])
STUDY CONCLUSION INVESTIGATOR INSTRUCTIONS
Item
STUDY CONCLUSION INVESTIGATOR INSTRUCTIONS
integer
C1707478 (UMLS CUI [1,1])
C0008972 (UMLS CUI [1,2])
C1442085 (UMLS CUI [1,3])
Item Group
PREGNANCY INFORMATION
Item Group
Pregnancy Information
C0032961 (UMLS CUI-1)
C1533716 (UMLS CUI-2)
Item
Did the subject become pregnant during the study? (mark one box below)
text
C3828490 (UMLS CUI [1])
Pregnant during study
Code List
Did the subject become pregnant during the study? (mark one box below)
CL Item
Not applicable (not of childbearing potential or male) (X)
CL Item
Yes (Y)
CL Item
No (N)
Item
Did the female partner of a male patient become pregnant during the study? (mark one box below)
text
C0919624 (UMLS CUI [1,1])
C0347984 (UMLS CUI [1,2])
C0008972 (UMLS CUI [1,3])
undefined item
Code List
Did the female partner of a male patient become pregnant during the study? (mark one box below)
CL Item
Not applicable (subject is female, female partner not of childbearing potential or no female partner) (X)
CL Item
Yes (Y)
CL Item
No (N)
Item Group
Study Conclusion
C1707478 (UMLS CUI-1)
C0008976 (UMLS CUI-2)
C0042210 (UMLS CUI-3)
John Hopkins RLS Quality of Life questionnaire
Item
John Hopkins RLS Quality of Life questionnaire
text
C0034394 (UMLS CUI [1,1])
C0034380 (UMLS CUI [1,2])
C0679830 (UMLS CUI [1,3])
C0035258 (UMLS CUI [1,4])
MEDICAL OUTCOMES STUDY SLEEP SCALE
Item
MEDICAL OUTCOMES STUDY SLEEP SCALE
integer
C0449820 (UMLS CUI [1,1])
C0037313 (UMLS CUI [1,2])
Profile of mood states
Item
Profile of mood states
text
C0451394 (UMLS CUI [1])
Hospital anxiety and depression scale
Item
Hospital anxiety and depression scale
text
C3539657 (UMLS CUI [1])
Pittsburgh Sleep quality index
Item
Pittsburgh Sleep quality index
text
C0424563 (UMLS CUI [1])
Patient global improvement scale
Item
Patient global improvement scale
text
C0451125 (UMLS CUI [1])
Item
PATIENT SATISFACTION QUESTION
text
C3476649 (UMLS CUI [1])
PATIENT SATISFACTION QUESTION
Code List
PATIENT SATISFACTION QUESTION
CL Item
Very satisfied (Very satisfied)
C3840671 (UMLS CUI-1)
(Comment:en)
CL Item
Satisfied (Satisfied)
C4084799 (UMLS CUI-1)
(Comment:en)
CL Item
Somewhat satisfied (Somewhat satisfied)
C4053811 (UMLS CUI-1)
(Comment:en)
CL Item
Neither satisfied nor dissatisfied (Neither satisfied nor dissatisfied)
C4050008 (UMLS CUI-1)
(Comment:en)
CL Item
Somewhat dissatisfied (Somewhat dissatisfied)
C4054006 (UMLS CUI-1)
(Comment:en)
CL Item
Dissatisfied (Dissatisfied)
C4085546 (UMLS CUI-1)
(Comment:en)
CL Item
Very dissatisfied (Very dissatisfied)
C3843339 (UMLS CUI-1)
(Comment:en)
Serious Adverse Event
Item
Did the subject experience any Serious Adverse Event during the study period ?
boolean
C1519255 (UMLS CUI [1])
Number of SAEs
Item
Total number of SAE's:
integer
C0449788 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
elimination criteria
Item
Did any elimination criteria become applicable during the study?
boolean
C0680251 (UMLS CUI [1])
elimination criteria
Item
Did any elimination criteria become applicable during the study? If Yes, please specify
text
C0680251 (UMLS CUI [1])
withdrawn
Item
Was the subject withdrawn from study?
boolean
C2349954 (UMLS CUI [1,1])
C0008976 (UMLS CUI [1,2])
Item
Please tick the ONE most appropriate category for drop out
integer
C2349954 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
reason for withdrawal
Code List
Please tick the ONE most appropriate category for drop out
CL Item
Serious adverse event (1)
CL Item
Other (7)
CL Item
Lost to follow-up (6)
CL Item
Migrated / moved from the study area (5)
CL Item
Consent withdrawal, not due to an adverse event. (4)
CL Item
Protocol violation (3)
CL Item
Non-Serious adverse event (2)
SAE Number
Item
SAE Number
integer
C1519255 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
AE Number
Item
AE Number or Code
integer
C1518404 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Protocol violation
Item
If Protocol violation, please specify
text
C1709750 (UMLS CUI [1])
Other reason for withdrawal
Item
Other reason for withdrawal
text
C2349954 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
Item
reason for withdrawal, Who made the decision?
integer
C2349954 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0008976 (UMLS CUI [1,3])
reason for withdrawal
Code List
reason for withdrawal, Who made the decision?
CL Item
Parents/Guardian’s decision (2)
CL Item
Investigator’s decision (1)
Date of last contact
Item
Date of last contact
date
C0011008 (UMLS CUI [1,1])
C1705415 (UMLS CUI [1,2])
Item
Was the subject in good condition at date of last contact?
integer
C1142435 (UMLS CUI [1,1])
C0681850 (UMLS CUI [1,2])
subject condition
Code List
Was the subject in good condition at date of last contact?
CL Item
Yes (2)
CL Item
No, please give details within the Adverse Events section (1)
Investigators signature
Item
Investigators signature
text
C2346576 (UMLS CUI [1])
Investigators signature Date
Item
Investigators signature Date
date
C0011008 (UMLS CUI [1,1])
C2346576 (UMLS CUI [1,2])
Item Group
RLS Symptoms on the first day of the patient
C1457887 (UMLS CUI-1)
C0035258 (UMLS CUI-2)
date
Item
Date
date
C0011008 (UMLS CUI [1])
medication
Item
1. Did you take your study medication during the period listed above?
boolean
C0013227 (UMLS CUI [1])
time medication intake
Item
If Yes, what time:
time
C0040223 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C1512806 (UMLS CUI [1,3])
Symptoms RLS
Item
2. Did you experience any RLS symptoms during the period listed above?
boolean
C1457887 (UMLS CUI [1,1])
C0035258 (UMLS CUI [1,2])
time
Item
3. What was the first time your RLS symptoms began?
time
C0040223 (UMLS CUI [1])
time fall sleep
Item
4. What time did you fall asleep?
time
C0040223 (UMLS CUI [1,1])
C3830397 (UMLS CUI [1,2])
time wake up
Item
5. What time did you wake up the following morning?
time
C0040223 (UMLS CUI [1,1])
C1170730 (UMLS CUI [1,2])
Item
6. Which parts of your body were affected by RLS symptoms during the period listed above?
integer
C1515974 (UMLS CUI [1])
site
Code List
6. Which parts of your body were affected by RLS symptoms during the period listed above?
CL Item
Most of the body (5)
CL Item
Arms and legs (4)
CL Item
Below the hips (3)
CL Item
Below the knees (2)
CL Item
None (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 7 a.m. to 11:59 a.m.
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 12 p.m. to 2:59 p.m.Noon
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 3 p.m. to 5:59 p.m.
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 6 p.m. to 8:59 p.m.
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 9 p.m. to 11:59 p.m.
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 12 a.m. to 6:59 a.m. Midnight
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
Item Group
RLS Symptoms on the first day of the patient
C1457887 (UMLS CUI-1)
C0035258 (UMLS CUI-2)
date
Item
Date
date
C0011008 (UMLS CUI [1])
medication
Item
1. Did you take your study medication during the period listed above?
boolean
C0013227 (UMLS CUI [1])
time medication intake
Item
If Yes, what time:
time
C0040223 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C1512806 (UMLS CUI [1,3])
Symptoms RLS
Item
2. Did you experience any RLS symptoms during the period listed above?
boolean
C1457887 (UMLS CUI [1,1])
C0035258 (UMLS CUI [1,2])
time
Item
3. What was the first time your RLS symptoms began?
time
C0040223 (UMLS CUI [1])
time fall sleep
Item
4. What time did you fall asleep?
time
C0040223 (UMLS CUI [1,1])
C3830397 (UMLS CUI [1,2])
time wake up
Item
5. What time did you wake up the following morning?
time
C0040223 (UMLS CUI [1,1])
C1170730 (UMLS CUI [1,2])
Item
6. Which parts of your body were affected by RLS symptoms during the period listed above?
integer
C1515974 (UMLS CUI [1])
site
Code List
6. Which parts of your body were affected by RLS symptoms during the period listed above?
CL Item
Most of the body (5)
CL Item
Arms and legs (4)
CL Item
Below the hips (3)
CL Item
Below the knees (2)
CL Item
None (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 7 a.m. to 11:59 a.m.
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 12 p.m. to 2:59 p.m.Noon
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 3 p.m. to 5:59 p.m.
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 6 p.m. to 8:59 p.m.
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 9 p.m. to 11:59 p.m.
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
time frame
Item
7. Did you have RLS symptoms in this time frame?- 12 a.m. to 6:59 a.m. Midnight
boolean
C0332168 (UMLS CUI [1])
Item
8. What was the maximum severity of your RLS symptoms during this time frame?
text
C1319166 (UMLS CUI [1])
symptom severity
Code List
8. What was the maximum severity of your RLS symptoms during this time frame?
CL Item
Very Severe (Very Severe)
CL Item
Severe (Severe)
CL Item
Moderate (Moderate)
CL Item
Mild (Mild)
CL Item
None (None)
Item
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
integer
C1457887 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])
symptom Beginning
Code List
9. At any times you were sitting or resting, how soon afterwards did your RLS symptoms start during this time frame?
CL Item
Did not sit or rest during this time frame (6)
CL Item
Immediately or almost immediately (5)
CL Item
Within a few minutes (4)
CL Item
After about half an hour (3)
CL Item
After about an hour (2)
CL Item
After a very long time or never (1)
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