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Patient enrollment form GSK Ropinirole in Patients Suffering from Restless Legs Syndrome 101468/190

- 10/18/17 - 1 form, 1 itemgroup, 10 items, 1 language
Itemgroup: Patient enrollment
Study ID: 101468/190 Clinical Study ID: SKF-101468/190 Study Title:A 12 Week, Double-Blind, Placebo-Controlled, Parallel Group Study to Assess the Efficacy and Safety of Ropinirole in Patients Suffering from Restless Legs Syndrome (RLS). Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Requip Study Indication: Restless Legs Syndrome This is the Patient enrollment form.

Screening GSK Ropinirole in Patients Suffering from Restless Legs Syndrome 101468/190

- 10/18/17 - 1 form, 14 itemgroups, 178 items, 1 language
Itemgroups: General Information, RLS SCREEN HISTORY, RLS DIAGNOSTIC CRITERIA, DEMOGRAPHY, VITAL SIGNS, ELECTROCARDIOGRAM (12 LEAD), PHYSICAL EXAMINATION, LABORATORY EVALUATION, URINE DIPSTICK, PREGNANCY DIPSTICK, SIGNIFICANT MEDICAL/SURGICAL HISTORY AND PHYSICAL EXAMINATION, PRIOR AND CONCOMITANT MEDICATION, RLS PHARMACOTHERAPY HISTORY, SCREENING INCLUSION/EXCLUSION CRITERIA
Study ID: 101468/190 Clinical Study ID: SKF-101468/190 Study Title:A 12 Week, Double-Blind, Placebo-Controlled, Parallel Group Study to Assess the Efficacy and Safety of Ropinirole in Patients Suffering from Restless Legs Syndrome (RLS). Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Requip Study Indication: Restless Legs Syndrome This is the Screening form.

Investigators Statement Ropinirole Case Report Form GSK RRL100013

- 10/1/17 - 1 form, 1 itemgroup, 8 items, 1 language
Itemgroup: Statement investigator
Investigators Statement Ropinirole Case Report Form 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

KBV Report to the medical service of health insurances Template 11

- 9/6/17 - 1 form, 3 itemgroups, 22 items, 1 language
Itemgroups: Report to the medical service of health insurances, Enclosed Documents, Footer
Muster 11 - Bericht für den Medizinischen Dienst (Freigabe 31.10.2014) - 1.2015, Formulare für die vertragsärztliche Versorgung - Freigabe durch Dezernat 4 - Ärztliche Leistungen und Versorgungsstruktur Geschäftsbereich Sicherstellung und Versorgungsstruktur Abteilung Sicherstellung Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Quelle: http://www.kbv.de/html/formulare.php Forms for contract medical care Released by Department 4 - Medical treatment and structure of supply, division ensurance and structure of supply, department ensurance Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Source: http://www.kbv.de/html/formulare.php

GSK non-inferiority of Tritanrix Hepatitis B PRE STUDY CONTACT VISIT NCT00290303 - GSK non-inferiority of Tritanrix Hepatitis B PRE STUDY CONTACT VISIT NCT00290303

- 8/14/17 - 1 form, 5 itemgroups, 22 items, 1 language
Itemgroups: General Information, Informed Consent, Demographics, PROTOCOL REQUIRED CONCOMITANT VACCINATION, Adverse Events
Study ID: 100478 Clinical Study ID: 100478 Study Title: Study to show non-inferiority of Tritanrix™-HepB/Hib-MenAC (+/- hepatitis B vaccine at birth) versus Tritanrix™-HepB/Hiberix™ without hepatitis B vacc. at birth for antibody response to all vaccine antigens given in healthy infants Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00290303 Sponsor: GlaxoSmithKline Phase: phase 3 Study Recruitment Status: Completed Generic Name: Combined Diphtheria, Tetanus, Whole Cell Pertussis, Hepatitis B, Haemophilus influenzae Type b Vaccine Trade Name: Tritanrix HepB/Hiberix Study Indication: Diphtheria; Haemophilus influenzae type b; Hepatitis B; Tetanus; Whole Cell Pertussis This form contains the PRE STUDY CONTACT VISIT

Extensive Swelling Report Hib-MenCY-TT-004 BST 003 Neisseria Meningitidis-Haemophilus influenzae type b Vaccine 100381 - Extensive Swelling Report

- 7/17/17 - 1 form, 1 itemgroup, 26 items, 1 language
Itemgroup: Report Swelling
Study part: Extensive Swelling Report. A phase 2 study to assess safety, reactogenicity and immunogenicity of a booster dose of an investigational vaccination regimen and GSK Biologicals Hib-MenC vaccine (co-administered with Infanrix penta) compared to a booster dose of Menjugate (co-administered with Infanrix hexa).Patient Level Data: Study Listed on ClinicalStudyDataRequest.com. Study ID: 100381, Clinical Study ID: 100381

Report (EHR Archetype) - openEHR-EHR-COMPOSITION.report.v1

- 7/8/17 - 1 form, 1 itemgroup, 5 items, 4 languages
Itemgroup: openEHR-EHR-COMPOSITION.report.v1.xml
Derived from www.openehr.org. Use as a generic archetype to carry information that needs to be shared with others. Common use cases are: documenting a response to a request for information; the outcome of testing; activities that have been performed; or events that have occurred. The Sections component has been deliberately left unconstrained to maximise re-use of this archetype.

Bronchoscopy Nursing Report Hematology UKM - Bronchoscopy Nursing Repor

- 3/27/17 - 1 form, 3 itemgroups, 24 items, 2 languages
Itemgroups: Patient demographics, Bronchoscopy, Footer module
Bronchoscopy Nursing Repor converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by: Prof. Dr. Berdel

University Hospital Essen Event

- 1/23/17 - 1 form, 1 itemgroup, 16 items, 1 language
Itemgroup: Event
Hospital routine documentation models at the University Hospital Essen. Tables were derived from the Medico Information System. Original table name: Event

AN STD Anamnese 01 MS University Hospital Muenster (UKM) Subform

- 11/26/16 - 1 form, 6 itemgroups, 44 items, 1 language
Itemgroups: General Information, Medical History, Childhood diseases, Family illness, Social and personal history, Medical History; Autonomic nervous system
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: AN STD Anamnese 01.

OP MS KICH Bericht MS University Hospital Muenster (UKM) Subform

- 11/24/16 - 1 form, 1 itemgroup, 10 items, 1 language
Itemgroup: General information
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: OP MS KICH Bericht.

Report Endo Mag Copsy University Hospital Muenster (UKM) Subform

- 10/27/16 - 1 form, 1 itemgroup, 6 items, 1 language
Itemgroup: Endoscopy report
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: Befund Endo Mag Copsy Sub

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