PHARMACEUTICAL CLINICAL TRIAL PATIENT SURVEY CHECKLIST

Created by ChecklistGuro (https://checklistguro.com)


--- PATIENT DEMOGRAPHICS ---
[ ] Age (Years)
[ ] Gender (Male, Female, Other, Prefer not to say)
[ ] Race/Ethnicity (White, Black or African American, Asian, Hispanic or Latino, Native American or Alaska Native, Other, Prefer not to say)
[ ] City of Residence
[ ] Date of Birth
[ ] Referring Physician (Optional)

--- INFORMED CONSENT & STUDY UNDERSTANDING ---
[ ] Have you read and understood the Study Information Sheet? (Yes, No)
[ ] Please describe, in your own words, the purpose of the study.
[ ] Do you understand the potential risks and benefits of participating in this study? (Yes, No, Not Sure)
[ ] Do you have any questions about the study procedures?
[ ] Date Informed Consent was Obtained
[ ] Patient Signature
[ ] Do you understand that you are free to withdraw from the study at any time? (Yes, No)

--- MEDICATION ADHERENCE ---
[ ] Number of doses taken as prescribed yesterday
[ ] How often did you miss a dose yesterday? (Never, Rarely (1-2 times), Sometimes (3-5 times), Frequently (More than 5 times))
[ ] Please explain any reasons for missed doses yesterday.
[ ] Date of last missed dose (if applicable)
[ ] Did you experience any difficulties taking your medication? (No, Yes)
[ ] (If Yes) Please describe the difficulties you experienced.

--- ADVERSE EVENTS REPORTING ---
[ ] Date of Adverse Event
[ ] Time of Adverse Event
[ ] Severity of Event (Mild, Moderate, Severe) (Mild, Moderate, Severe)
[ ] Detailed Description of Adverse Event
[ ] Event Duration (in minutes)
[ ] Body Areas Affected (Select all that apply) (Skin, Gastrointestinal, Neurological, Respiratory, Cardiovascular, Other)
[ ] Actions Taken to Address Adverse Event

--- TREATMENT EFFICACY ASSESSMENT ---
[ ] Pain Level (0-10)
[ ] Overall Improvement Compared to Baseline (Much Worse, Slightly Worse, No Change, Slightly Improved, Much Improved)
[ ] Describe any improvements you’ve experienced.
[ ] Severity of Symptom X (0-10)
[ ] How would you rate the effectiveness of the treatment? (Very Ineffective, Ineffective, Neutral, Effective, Very Effective)

--- QUALITY OF LIFE (QOL) IMPACT ---
[ ] Overall Quality of Life Score (0-100)
[ ] How has your energy level changed? (Increased, Decreased, No Change)
[ ] How has your mood been overall? (Very Positive, Positive, Neutral, Negative, Very Negative)
[ ] Sleep Duration (hours per night)
[ ] Please describe any changes you've noticed in your daily activities.
[ ] How would you rate your ability to perform household chores? (Much Easier, Easier, No Change, More Difficult, Much More Difficult)

--- STUDY SATISFACTION & FEEDBACK ---
[ ] Overall, how satisfied were you with your experience in this clinical trial? (Very Satisfied, Satisfied, Neutral, Dissatisfied, Very Dissatisfied)
[ ] On a scale of 1 to 10 (1 being not at all likely, 10 being extremely likely), how likely are you to recommend this clinical trial to others?
[ ] What did you like most about participating in this clinical trial?
[ ] What aspects of the clinical trial could be improved?
[ ] How would you rate the communication from the research team? (Excellent, Good, Fair, Poor)
[ ] Do you have any additional comments or suggestions?

--- PROTOCOL COMPLIANCE VERIFICATION ---
[ ] Date of Last Medication Administration (as per protocol)
[ ] Number of Visits Completed (as per schedule)
[ ] Was fasting required prior to blood draws (as per protocol)? (Yes, No, Not Applicable)
[ ] Which procedures were performed during the last visit (as per protocol)? (Physical Examination, Blood Draw, ECG, Questionnaire, Other)
[ ] Describe any deviations from the protocol observed or encountered.
[ ] Were all inclusion/exclusion criteria still met at the last visit? (Yes, No, Not Reviewed)

--- FOLLOW-UP VISIT READINESS ---
[ ] Scheduled Follow-Up Visit Date
[ ] Scheduled Follow-Up Visit Time
[ ] Follow-Up Visit Location
[ ] Transportation Method to Visit (Car, Public Transportation, Ride-Sharing Service, Other)
[ ] Estimated Travel Time (minutes)
[ ] Have you received appointment reminders? (Yes, No)
[ ] Any concerns or questions for the next visit?

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