Aids clinical trials unit

AIDS CLINICAL TRIALS UNIT
PATIENT QUESTIONNAIRE
Mailing Information:
City, State, ZIP:
E mail Address:
Date of Birth:
Would you like to be entered into our data base?
Yes No
Would you like to receive mailings about
Via E mail ? Yes No N/A
studies and events at the above address?
Phone Number Home :
Phone Number Work :
May we call you home? Yes No
May we call you at work? Yes No
Primary Physician / Clinic:
How did you hear about us?
Symptoms/History
Opportunistic Infections :
__________________________________ Date :___________________
__________________________________ Date :___________________
__________________________________ Date :___________________
__________________________________ Date :___________________
Tcells - most recent count :
Tcells - most recent date :
RNA - most recent count :
RNA - most recent date :

Antiretroviral Therapy : (Please include any past use as well)
Medication
Date Started Date Stopped If Stopped, why?
AZT (Zidovudine, Retrovir)
ddI (Didanosine, Videx
ddC (Zalcitabine, Hivid)
d4T (Stavudine, Zerit)
3TC (Lamivudine, Epivir)
Combivir (AZT + 3TC)
Efavirenz (Sustiva)
Antiretroviral Therapy - Continue: (Please include any past use as well)
Medication
Date Started Date Stopped If Stopped, why?
Adefovir ( Preveon)
Abacavir (1592U89, Ziagen)
Amprenavir ( 141W94,
Agenerase)
Saquinavir hard gel cap (Invirase)
Saquinavir soft gel cap
(Fortovase)
Nelfinavir ( Viracept )
Ritonavir (Norvir)
Indinavir ( Crixivan)
Delavirdine (Rescriptor)
Nevirapine (Viramune)
ABT - 378/r
Tenofovir
Prophylaxis/Other (please circle ALL taken)
Septra Dapsone A.Pentamidine Atovaquone Azythromycin Clarithromycin
Ethambutol Oral Ganciclovir rhNGF (human nerve Growth factor) HIV vaccines
Hydroxyurea GP 160 IL - 2
Other : _______________ ________________ ________________ ______________ ___________
In which studies are you interested?
____________________________________________________________________________________________
Comments: __________________________________________________________________________________
__________________________________________________________________________________

Please complete this questionnaire and return it to : Stanford University medical Center
ACTU,
Stanford,
94305-5107
Or fax to (650) 498-7874
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For ACTU use only
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Screened : Y N Protocol ___________
Excluded : Y N If "Y" - reason _________________________________________________

Source: http://actu.stanford.edu/pdf-word/Questionnaire.pdf