1 |
[study_id] |
Study ID |
text |
2 |
[date_enrolled] |
Section Header: Consent Information
Date subject signed consentYYYY-MM-DD
|
text (date_ymd) |
3 |
[patient_document] |
Upload the patient's consent form |
file |
4 |
[first_name] |
Section Header: Contact Information
First Name
|
text, Identifier |
5 |
[last_name] |
Last Name |
text, Identifier |
6 |
[address] |
Street, City, State, ZIP |
notes, Identifier |
7 |
[telephone_1] |
Phone number Include Area Code
|
text (phone), Identifier |
8 |
[email] |
E-mail |
text (email), Identifier |
9 |
[dob] |
Date of birth |
text (date_ymd), Identifier |
10 |
[age] |
Age (years) |
calc Calculation: rounddown(datediff([dob],'today','y')) |
11 |
[ethnicity] |
Ethnicity |
radio0 | Hispanic or Latino | 1 | NOT Hispanic or Latino | 2 | Unknown / Not Reported |
Custom alignment: LH |
12 |
[race] |
Race |
dropdown0 | American Indian/Alaska Native | 1 | Asian | 2 | Native Hawaiian or Other Pacific Islander | 3 | Black or African American | 4 | White | 5 | More Than One Race | 6 | Unknown / Not Reported |
|
13 |
[gender] |
Gender |
radio0 | Female | 1 | Male | 2 | Other | 3 | Prefer not to say |
|
14 |
[given_birth]
Show the field ONLY if:
[gender] = "0"
|
Has the patient given birth before? |
yesno |
15 |
[num_children]
Show the field ONLY if:
[gender] = "0" and [given_birth] = "1"
|
How many times has the patient given birth? |
text (integer, Min: 0) |
16 |
[gym] |
Section Header: Please provide the patient's weekly schedule for the activities below.
Gym (Weight Training)
|
checkbox0 | gym___0 | Monday | 1 | gym___1 | Tuesday | 2 | gym___2 | Wednesday | 3 | gym___3 | Thursday | 4 | gym___4 | Friday |
|
17 |
[aerobics] |
Aerobics |
checkbox0 | aerobics___0 | Monday | 1 | aerobics___1 | Tuesday | 2 | aerobics___2 | Wednesday | 3 | aerobics___3 | Thursday | 4 | aerobics___4 | Friday |
|
18 |
[eat] |
Eat Out (Dinner/Lunch) |
checkbox0 | eat___0 | Monday | 1 | eat___1 | Tuesday | 2 | eat___2 | Wednesday | 3 | eat___3 | Thursday | 4 | eat___4 | Friday |
|
19 |
[drink] |
Drink (Alcoholic Beverages) |
checkbox0 | drink___0 | Monday | 1 | drink___1 | Tuesday | 2 | drink___2 | Wednesday | 3 | drink___3 | Thursday | 4 | drink___4 | Friday |
|
20 |
[specify_mood] |
Section Header: Other information
Specify the patient's mood
|
slider Slider labels: Very sad, Indifferent, Very happy |
21 |
[meds] |
Is patient taking any of the following medications? (check all that apply) |
checkbox1 | meds___1 | Lexapro | 2 | meds___2 | Celexa | 3 | meds___3 | Prozac | 4 | meds___4 | Paxil | 5 | meds___5 | Zoloft |
|
22 |
[height] |
Height (cm) |
text (number, Min: 130, Max: 215) |
23 |
[weight] |
Weight (kilograms) |
text (integer, Min: 35, Max: 200) |
24 |
[bmi] |
BMI |
calc Calculation: round(([weight]*10000)/(([height])^(2)),1) |
25 |
[comments] |
Section Header: General Comments
Comments
|
notes |
26 |
[demographics_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
27 |
[height2] |
Height (cm) |
text (number) |
28 |
[weight2] |
Weight (kilograms) |
text (integer) |
29 |
[bmi2] |
BMI |
calc Calculation: round(([weight2]*10000)/(([height2])^(2)),1) |
30 |
[prealb_b] |
Serum Prealbumin (mg/dL) |
text (number) |
31 |
[creat_b] |
Creatinine (mg/dL) |
text (number) |
32 |
[npcr_b] |
Normalized Protein Catabolic Rate (g/kg/d) |
text (number) |
33 |
[chol_b] |
Cholesterol (mg/dL) |
text (number) |
34 |
[transferrin_b] |
Transferrin (mg/dL) |
text (number) |
35 |
[baseline_data_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
36 |
[vld1] |
Serum Prealbumin (mg/dL) |
text (number) |
37 |
[vld2] |
Creatinine (mg/dL) |
text (number) |
38 |
[vld3] |
Normalized Protein Catabolic Rate (g/kg/d) |
text (number) |
39 |
[vld4] |
Cholesterol (mg/dL) |
text (number) |
40 |
[vld5] |
Transferrin (mg/dL) |
text (number) |
41 |
[visit_lab_data_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
42 |
[pmq1] |
On average, how many pills did you take each day last week? |
dropdown0 | less than 5 | 1 | 5-10 | 2 | 6-15 | 3 | over 15 |
|
43 |
[pmq2] |
Using the handout, which level of dependence do you feel you are currently at? |
dropdown |
44 |
[pmq3] |
Would you be willing to discuss your experiences with a psychiatrist? |
radio |
45 |
[pmq4] |
How open are you to further testing? |
dropdown0 | not open | 1 | undecided | 2 | very open |
|
46 |
[patient_morale_questionnaire_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
47 |
[vbw1] |
Serum Prealbumin (mg/dL) |
text (number) |
48 |
[vbw2] |
Creatinine (mg/dL) |
text (number) |
49 |
[vbw3] |
Normalized Protein Catabolic Rate (g/kg/d) |
text (number) |
50 |
[vbw4] |
Cholesterol (mg/dL) |
text (number) |
51 |
[vbw5] |
Transferrin (mg/dL) |
text (number) |
52 |
[vbw6] |
Blood draw shift? |
radio |
53 |
[vbw7] |
Blood draw by |
radio0 | RN | 1 | LPN | 2 | nurse assistant | 3 | doctor |
|
54 |
[vbw8] |
Level of patient anxiety |
dropdown0 | not anxious | 1 | undecided | 2 | very anxious |
|
55 |
[vbw9] |
Patient scheduled for future draws? |
dropdown |
56 |
[visit_blood_workup_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
57 |
[vob1] |
Section Header: Was the patient...
nervous?
|
radio |
58 |
[vob2] |
worried? |
radio |
59 |
[vob3] |
scared? |
radio |
60 |
[vob4] |
fidgety? |
radio |
61 |
[vob5] |
crying? |
radio |
62 |
[vob6] |
screaming? |
radio |
63 |
[vob7] |
other |
notes |
64 |
[vob8] |
Section Header: Were you...
nervous?
|
radio |
65 |
[vob9] |
worried? |
radio |
66 |
[vob10] |
scared? |
radio |
67 |
[vob11] |
fidgety? |
radio |
68 |
[vob12] |
crying? |
radio |
69 |
[vob13] |
screaming? |
radio |
70 |
[vob14] |
other |
notes |
71 |
[visit_observed_behavior_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
72 |
[study_comments] |
Comments |
notes |
73 |
[complete_study] |
Has patient completed study? |
dropdown |
74 |
[withdraw_date] |
Put a date if patient withdrew study |
text (date_ymd) |
75 |
[date_visit_4] |
Date of last visit |
text (date_ymd) |
76 |
[alb_4] |
Serum Albumin (g/dL) |
text (number) |
77 |
[prealb_4] |
Serum Prealbumin (mg/dL) |
text (number) |
78 |
[creat_4] |
Creatinine (mg/dL) |
text (date_ymd) |
79 |
[discharge_date_4] |
Date of hospital discharge |
text (date_ymd) |
80 |
[discharge_summary_4] |
Discharge summary in patients binder? |
dropdown |
81 |
[npcr_4] |
Normalized Protein Catabolic Rate (g/kg/d) |
text (integer) |
82 |
[chol_4] |
Cholesterol (mg/dL) |
text (integer) |
83 |
[withdraw_reason] |
Reason patient withdrew from study |
dropdown0 | Non-compliance | 1 | Did not wish to continue in study | 2 | Could not tolerate the supplement | 3 | Hospitalization | 4 | Other |
|
84 |
[completion_data_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
85 |
[cpq1] |
Date of study completion |
text (date_ymd) |
86 |
[cpq2] |
Transferrin (mg/dL) |
text (integer) |
87 |
[cpq3] |
Kt/V |
text (integer) |
88 |
[cpq4] |
Dry weight (kilograms) |
text (integer) |
89 |
[cpq5] |
Number of treatments missed |
text (integer) |
90 |
[cpq6] |
How compliant was the patient in drinking the supplement? |
dropdown0 | 100 percent | 1 | 99-75 percent | 2 | 74-50 percent | 3 | 49-25 percent | 4 | 0-24 percent |
|
91 |
[cpq7] |
Was patient hospitalized since last visit? |
dropdown |
92 |
[cpq8] |
What was the cause of hospitalization? |
dropdown1 | Vascular access related events | 2 | CVD events | 3 | Other |
|
93 |
[cpq9] |
Date of hospital admission |
text (date_ymd) |
94 |
[cpq10] |
On average, how many pills did you take each day last week? |
dropdown0 | less than 5 | 1 | 5-10 | 2 | 6-15 | 3 | over 15 |
|
95 |
[cpq11] |
Using the handout, which level of dependence do you feel you are currently at? |
dropdown |
96 |
[cpq12] |
Would you be willing to discuss your experiences with a psychiatrist? |
radio |
97 |
[cpq13] |
How open are you to further testing? |
dropdown0 | not open | 1 | undecided | 2 | very open |
|
98 |
[completion_project_questionnaire_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|