PRL1013 - Week 4 Recall Evaluation Form NCT01268605 Postoperative Hypersensitivity Randomized Comparative Effectiveness Research Trial (POH RCERT) Source Form: NCI FormBuilder:

  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/27/15 6/27/15 -
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June 27, 2015

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Creative Commons BY-NC 3.0 Legacy
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PRL1013 - Week 4 Recall Evaluation Form NCT01268605

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  1. StudyEvent: PRL1013 - Week 4 Recall Evaluation Form
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Treatment arm
Dental status
Tooth quadrant
Air stimulation pain level
Does the pain linger >4 seconds (after removal of air blast)
Cold stimulation pain level
Does the pain linger > 4 seconds
During chewing of food
During clenching
Did you check the occlusion on the treated tooth (If "Yes" to either of the above)
Did you adjust the occlusion (If "Yes")
Rescue Treatment
Did the patient receive rescue treatment (since the last visit)
Which rescue treatment was provided
Was the tooth evaluated for pulpitis
Was there evidence of pulpitis (If "Yes")
Was endodontic therapy performed (If "Yes")
Economic Impact
How much time did it take the patient to travel to the dental office today
How much did it cost the patient to travel to the dental office today (including parking)
Did the patient have to take time away from work to come to the dental office to treat the hypersensitivity
How much time did he/she take off (If "Yes")
What is the total estimated cost for the rescue treatment if patient was not participating in the study
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