Unnamed2
PatientName
text
Participating Group
text
Medical Record Number
text
Study Number Participating Group
text
Institution Name
text
Trial subject ID Participating Group
text
Unnamed3
Person Completing Form
text
TreatmentReportingPeriodNumber
text
Unnamed4
Methodofassessment
text
datequestionnairewassenttopatient
date
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
float
Languageinwhichassessmentwasconducted
text
Other,specify(languageinwhichassessmentwasconducted)
text
Qualityoflifeassessment
text
numberofQOLinstrument(s)completed
float
Iftheassessmentwaspartiallycompletedornotdone,indicatereason(s)below
text
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
text