Clinical Trial - Longitudinal clinical_trial_3 clinical_trial_3 Clinical Trial - Longitudinal Clinical Trial - Longitudinal clinical_trial_3.xml Demographics Baseline Data Visit Lab Data Patient Morale Questionnaire Visit Blood Workup Visit Observed Behavior Completion Data Completion Project Questionnaire Study ID Study ID Study ID Note 0 Date subject signed consent Date subject signed consent Field Note : YYYY-MM-DD 0 Upload the patient's consent form Upload the patient's consent form 0 First Name First Name 0 Last Name Last Name 0 Street, City, State, ZIP Street, City, State, ZIP 0 Phone number Phone number Field Note : Include Area Code 0 E-mail E-mail 0 Date of birth Date of birth 0 Age (years) Age (years) Calculated : rounddown(datediff([dob],'today','y')) 0 Ethnicity Ethnicity 0 Hispanic or Latino 0 1 NOT Hispanic or Latino 0 2 Unknown / Not Reported 0 0 Race Race 0 American Indian/Alaska Native 0 1 Asian 0 2 Native Hawaiian or Other Pacific Islander 0 3 Black or African American 0 4 White 0 5 More Than One Race 0 6 Unknown / Not Reported 0 0 Gender Gender 0 Female 0 1 Male 0 2 Other 0 3 Prefer not to say 0 0 Has the patient given birth before? Has the patient given birth before? [gender] = "0" 1 Yes 0 0 No 0 0 How many times has the patient given birth? How many times has the patient given birth? [gender] = "0" and [given_birth] = "1" 0 Gym (Weight Training) Gym (Weight Training) 0 Monday 0 1 Tuesday 0 2 Wednesday 0 3 Thursday 0 4 Friday 0 0 Aerobics Aerobics 0 Monday 0 1 Tuesday 0 2 Wednesday 0 3 Thursday 0 4 Friday 0 0 Eat Out (Dinner/Lunch) Eat Out (Dinner/Lunch) 0 Monday 0 1 Tuesday 0 2 Wednesday 0 3 Thursday 0 4 Friday 0 0 Drink (Alcoholic Beverages) Drink (Alcoholic Beverages) 0 Monday 0 1 Tuesday 0 2 Wednesday 0 3 Thursday 0 4 Friday 0 0 Specify the patient's mood Specify the patient's mood Slider values : Specify the patient's mood : Very sad | Indifferent | Very happy 0 Is patient taking any of the following medications? (check all that apply) Is patient taking any of the following medications? (check all that apply) 1 Lexapro 0 2 Celexa 0 3 Prozac 0 4 Paxil 0 5 Zoloft 0 0 Height (cm) Height (cm) 0 Weight (kilograms) Weight (kilograms) 0 BMI BMI Calculated : round(([weight]*10000)/(([height])^(2)),1) 0 Comments Comments 0 Complete? Complete? 0 Incomplete 0 1 Unverified 0 2 Complete 0 0 Height (cm) Height (cm) 0 Weight (kilograms) Weight (kilograms) 0 BMI BMI Calculated : round(([weight2]*10000)/(([height2])^(2)),1) 0 Serum Prealbumin (mg/dL) Serum Prealbumin (mg/dL) 0 Creatinine (mg/dL) Creatinine (mg/dL) 0 Normalized Protein Catabolic Rate (g/kg/d) Normalized Protein Catabolic Rate (g/kg/d) 0 Cholesterol (mg/dL) Cholesterol (mg/dL) 0 Transferrin (mg/dL) Transferrin (mg/dL) 0 Complete? Complete? 0 Incomplete 0 1 Unverified 0 2 Complete 0 0 Serum Prealbumin (mg/dL) Serum Prealbumin (mg/dL) 0 Creatinine (mg/dL) Creatinine (mg/dL) 0 Normalized Protein Catabolic Rate (g/kg/d) Normalized Protein Catabolic Rate (g/kg/d) 0 Cholesterol (mg/dL) Cholesterol (mg/dL) 0 Transferrin (mg/dL) Transferrin (mg/dL) 0 Complete? Complete? 0 Incomplete 0 1 Unverified 0 2 Complete 0 0 On average, how many pills did you take each day last week? On average, how many pills did you take each day last week? 0 less than 5 0 1 5-10 0 2 6-15 0 3 over 15 0 0 Using the handout, which level of dependence do you feel you are currently at? Using the handout, which level of dependence do you feel you are currently at? 0 0 0 1 1 0 2 2 0 3 3 0 4 4 0 5 5 0 0 Would you be willing to discuss your experiences with a psychiatrist? Would you be willing to discuss your experiences with a psychiatrist? 0 No 0 1 Yes 0 0 How open are you to further testing? How open are you to further testing? 0 not open 0 1 undecided 0 2 very open 0 0 Complete? Complete? 0 Incomplete 0 1 Unverified 0 2 Complete 0 0 Serum Prealbumin (mg/dL) Serum Prealbumin (mg/dL) 0 Creatinine (mg/dL) Creatinine (mg/dL) 0 Normalized Protein Catabolic Rate (g/kg/d) Normalized Protein Catabolic Rate (g/kg/d) 0 Cholesterol (mg/dL) Cholesterol (mg/dL) 0 Transferrin (mg/dL) Transferrin (mg/dL) 0 Blood draw shift? Blood draw shift? 0 AM 0 1 PM 0 0 Blood draw by Blood draw by 0 RN 0 1 LPN 0 2 nurse assistant 0 3 doctor 0 0 Level of patient anxiety Level of patient anxiety 0 not anxious 0 1 undecided 0 2 very anxious 0 0 Patient scheduled for future draws? Patient scheduled for future draws? 0 No 0 1 Yes 0 0 Complete? Complete? 0 Incomplete 0 1 Unverified 0 2 Complete 0 0 nervous? nervous? 0 No 0 1 Yes 0 0 worried? worried? 0 No 0 1 Yes 0 0 scared? scared? 0 No 0 1 Yes 0 0 fidgety? fidgety? 0 No 0 1 Yes 0 0 crying? crying? 0 No 0 1 Yes 0 0 screaming? screaming? 0 No 0 1 Yes 0 0 other other 0 nervous? nervous? 0 No 0 1 Yes 0 0 worried? worried? 0 No 0 1 Yes 0 0 scared? scared? 0 No 0 1 Yes 0 0 fidgety? fidgety? 0 No 0 1 Yes 0 0 crying? crying? 0 No 0 1 Yes 0 0 screaming? screaming? 0 No 0 1 Yes 0 0 other other 0 Complete? Complete? 0 Incomplete 0 1 Unverified 0 2 Complete 0 0 Comments Comments 0 Has patient completed study? Has patient completed study? 0 No 0 1 Yes 0 0 Put a date if patient withdrew study Put a date if patient withdrew study 0 Date of last visit Date of last visit 0 Serum Albumin (g/dL) Serum Albumin (g/dL) 0 Serum Prealbumin (mg/dL) Serum Prealbumin (mg/dL) 0 Creatinine (mg/dL) Creatinine (mg/dL) 0 Date of hospital discharge Date of hospital discharge 0 Discharge summary in patients binder? Discharge summary in patients binder? 0 No 0 1 Yes 0 0 Normalized Protein Catabolic Rate (g/kg/d) Normalized Protein Catabolic Rate (g/kg/d) 0 Cholesterol (mg/dL) Cholesterol (mg/dL) 0 Reason patient withdrew from study Reason patient withdrew from study 0 Non-compliance 0 1 Did not wish to continue in study 0 2 Could not tolerate the supplement 0 3 Hospitalization 0 4 Other 0 0 Complete? Complete? 0 Incomplete 0 1 Unverified 0 2 Complete 0 0 Date of study completion Date of study completion 0 Transferrin (mg/dL) Transferrin (mg/dL) 0 Kt/V Kt/V 0 Dry weight (kilograms) Dry weight (kilograms) 0 Number of treatments missed Number of treatments missed 0 How compliant was the patient in drinking the supplement? How compliant was the patient in drinking the supplement? 0 100 percent 0 1 99-75 percent 0 2 74-50 percent 0 3 49-25 percent 0 4 0-24 percent 0 0 Was patient hospitalized since last visit? Was patient hospitalized since last visit? 0 No 0 1 Yes 0 0 What was the cause of hospitalization? What was the cause of hospitalization? 1 Vascular access related events 0 2 CVD events 0 3 Other 0 0 Date of hospital admission Date of hospital admission 0 On average, how many pills did you take each day last week? On average, how many pills did you take each day last week? 0 less than 5 0 1 5-10 0 2 6-15 0 3 over 15 0 0 Using the handout, which level of dependence do you feel you are currently at? Using the handout, which level of dependence do you feel you are currently at? 0 0 0 1 1 0 2 2 0 3 3 0 4 4 0 5 5 0 0 Would you be willing to discuss your experiences with a psychiatrist? Would you be willing to discuss your experiences with a psychiatrist? 0 No 0 1 Yes 0 0 How open are you to further testing? How open are you to further testing? 0 not open 0 1 undecided 0 2 very open 0 0 Complete? Complete? 0 Incomplete 0 1 Unverified 0 2 Complete 0 0