IIH:DT. Appointment Diary v2.0 20th May 2015
Page 6 of 5
[To be printed on yellow card]
The impact of AZD4017 on intracranial pressure and
symptoms in Idiopathic Intracranial Hypertension
IIH:DT Trial
Appointment Diary
Patient’s Name ___________________________________
Patient’s Study Number ____________________________
Contact:
Monday–Friday <<insert local contact hours
and telephone number>>
Any other time - Emergency contact
Tel: <<insert local switchboard>> (Switchboard)
Please ask for the Neurology on-call doctor
For all of your appointments, please bring with you:
-
this diary (yellow card)
your Diary of Events (green card)
24-hour urine collection (bottle given at previous visit)
Headache diary (if given)
Leftover medication / empty boxes and blister packs
On some study visits you are asked to attend fasting - this means that you
should have nothing to eat or drink apart from tap water for 10 hours prior
to your visit (although you are able to take any medications as usual).
IIH:DT. Appointment Diary v2.0 20th May 2015
Page 1 of 5
What
Visit 1 – Medication Day 1
- DXA scan
- Fat and skin sample
- Blood taken
- Prednisone (10mg)
administered. Bloods taken at
intervals
- Allocated to study drug and
receive medications
- Receive 24 hour urine bottle
Visit 2 – Medication Week 1
- Blood tests
- Review your Diary of Events
- Review your IIH symptoms
- Pregnancy test
- 24 hr urine sample collected
- Receive medications
- Receive 24 hr urine bottle for
Visit 3.
Visit 3 – Medication Week 4
- Blood tests
- Review your Diary of Events
- Review your IIH symptoms
- Pregnancy test
- 24 hour urine sample collected
- Receive medications
Receive 24 hr urine bottle for
Visit 4.
IIH:DT. Appointment Diary v2.0 20th May 2015
Date + time
Notes
of visit
Please attend
fasting.
Bring with you:
- this diary (yellow
card)
Bring with you:
- this diary (yellow
card)
- Diary of Events
(green card)
-24-hour urine
collection
- Leftover medication
or empty boxes
- Post-LP Headache
Diary
Bring with you:
- this diary (yellow
card)
- Diary of Events
(green card)
-24-hour urine
collection
- leftover medication
or empty boxes
Page 2 of 5
Telephone Consultation Week 6
- Review Diary of events
- Review IIH symptoms
Visit 4 – Medication Week 8
- Blood tests
- Review your Diary of Events
- Review your IIH symptoms
- Pregnancy test
- 24 hr urine sample collected
- Receive medications
- Receive 24 hr urine bottle for
Visit 5.
- Receive headache diary for
Visit 5.
Telephone Consultation Week
10
- Review Diary of events
- Review IIH symptoms
Visit 5 - Medication Week 12.
Day 1
- Eye and sight tests
- Review your Diary of Events
- Review your IIH symptoms
- Blood pressure, heart rate,
height and weight
- Collect headache diary
- Lumbar puncture
- Pregnancy test
- 24 hour urine sample collected
- Post-LP Headache Diary
received
IIH:DT. Appointment Diary v2.0 20th May 2015
Have with you:
- Diary of events
Bring with you:
- this diary (yellow
card)
- Diary of Events
(green card)
-24-hour urine
collection
- leftover medication
or empty boxes
Have with you:
- Diary of events
Bring with you:
- this diary (yellow
card)
- Diary of Events
(green card)
-24-hour urine
collection
- leftover medication
or empty boxes
-Headache diary
Page 3 of 5
Visit 6 - Medication Week 12Day 2
- DXA scan
- Fat and skin sample
- Blood taken
- Prednisone (10mg)
administered. Bloods taken at
intervals
- Return all medication and
packaging
- Receive 24 hour urine bottle
for Visit 7.
- Receive headache diary
Visit 7 – Follow-up at Week 16
- Eye and sight tests
- Blood tests
- Blood pressure, heart rate,
weight and height
- Pregnancy test
- Review your Diary of Events
- Review your IIH symptoms
- 24 hour urine sample collected
- Headache diary collected
IIH:DT. Appointment Diary v2.0 20th May 2015
Please attend
fasting.
Bring with you:
- this diary (yellow
card)
- leftover medication
or empty boxes
Ensure your
medication is taken
at 7am the morning
of your visit.
Please attend
fasting.
Bring with you:
- this diary (yellow
card)
- Diary of Events
(green card)
-24-hour urine
collection
- Headache diary
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