Outpatient Visit Data Form

HOSPITAL RESEARCH UNIT OUTPATIENT VISIT DATA FORM

PLEASE SEND COMPLETED FORM TO [email protected] OR fax to (203) 688-3100 IF YOU HAVE ANY QUESTIONS, PLEASE CALL 203 688-4106 HIC #: PI NAME: PI PHONE #: RESPONSIBLE MD NAME(IF APPLICABLE): Today’s Date: [Date] MD PHONE #: Date of Visit: [Date] COORDINATOR/RA NAME: Visit # : COORDINATOR/RA CONTACT #: Expected Time of Subject Arrival: HAS PATIENT SIGNED CONSENT: Choose an item. Expected Length of Appointment:

PATIENT INFORMATION Middle Marital status: [Choose an Patient’s Last Name: First: initial: item]

Age: Place of Birth (City, State, Maiden Name: MRUN#: Birth date: Choose Gender: Choose Country): an an item. item. Pt. Weight: [Birthday] Pt. Height: Address: [Address/ P.O Box, City, ST ZIP Code] Home phone #: Cell phone #: Work phone #:

Assistance needed for Does patient speak English: Choose an item. Is patient deaf or hearing impaired: Choose an item. communication: Choose an item. If not, language spoken:

Ethnicity: Choose an item. Race: Choose an item.

IN CASE OF EMERGENCY Name of local friend or relative: Relationship to patient: Home phone #: Cell phone #:

[Date] Form Submitted by Date