Research Study - Multiple Longitudinal Surveys
research_study_4
research_study_4
Research Study - Multiple Longitudinal Surveys
Research Study - Multiple Longitudinal Surveys
research_study_4.xml
Pre-Screening Survey
Participant Info Survey
Participant Morale Questionnaire
Completion Data (to be entered by study personnel only)
Participant ID
Participant ID
0
Date of birth
Date of birth
0
E-mail address
E-mail address
0
I currently have Type 2 Diabetes
I currently have Type 2 Diabetes
0
By checking this box, I certify that I am at least 18 years old and that I give my consent freely to participate in this study.
By checking this box, I certify that I am at least 18 years old and that I give my consent freely to participate in this study.
1
I consent
0
0
Complete?
Complete?
0
Incomplete
0
1
Unverified
0
2
Complete
0
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
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
Height (cm)
Height (cm)
0
Weight (kilograms)
Weight (kilograms)
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
The choices you made
The choices you made
1
Not satisfied at all
0
2
Somewhat dissatisfied
0
3
Indifferent
0
4
Somewhat satisfied
0
5
Very satisfied
0
0
Your life overall
Your life overall
1
Not satisfied at all
0
2
Somewhat dissatisfied
0
3
Indifferent
0
4
Somewhat satisfied
0
5
Very satisfied
0
0
Your job
Your job
1
Not satisfied at all
0
2
Somewhat dissatisfied
0
3
Indifferent
0
4
Somewhat satisfied
0
5
Very satisfied
0
0
Your family life
Your family life
1
Not satisfied at all
0
2
Somewhat dissatisfied
0
3
Indifferent
0
4
Somewhat satisfied
0
5
Very satisfied
0
0
Complete?
Complete?
0
Incomplete
0
1
Unverified
0
2
Complete
0
0
Has patient completed study?
Has patient completed study?
1
Yes
0
0
No
0
0
Put a date if patient withdrew study
Put a date if patient withdrew study
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
Date of last visit
Date of last visit
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
Complete?
Complete?
0
Incomplete
0
1
Unverified
0
2
Complete
0
0