Patient demographics
Patient Name
text
Participating Group
text
Medical Record Number
text
Study Number Participating Group
text
Institution Name
text
Trial subject ID Participating Group
text
Method of Evaluation
Methodofassessment
text
datequestionnairewassenttopatient
date
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
float
Languageinwhichassessmentwasconducted
text
Other,specify(languageinwhichassessmentwasconducted)
text
Qualityoflifeassessment
text
numberofQOLinstrument(s)completed
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Iftheassessmentwaspartiallycompletedornotdone,indicatereason(s)below
text
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
text
Footer module
Person Completing Form
text
TreatmentReportingPeriodNumber
text
Comments
text