Research Study - Longitudinal
research_study_3
research_study_3
Research Study - Longitudinal
Research Study - Longitudinal
research_study_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
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
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
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