Fixed Fields
| Alias | Question | Type | Options |
|---|---|---|---|
| firstName | Patient First Name | Freetext (mandatory) | |
| lastName | Patient Last Name | Freetext (mandatory) | |
| Patient Email Address | Freetext (mandatory) | ||
| phoneNumber | Patient Phone Number | Freetext (mandatory) | |
| address1 | Patient Address Line 1 | Freetext (mandatory) | |
| address2 | Patient Address Line 2 | Freetext (mandatory) | |
| city | Patient City | Freetext (mandatory) | |
| postalCode | Patient Postcode | Freetext (mandatory) | |
| birthDate | Patient Date of Birth | DateTime | |
| gender | Patients Gender | Dropdown |
FEMALE F MALE M NON_BINARY |
| sex | Patients Sex | Dropdown |
FEMALE F MALE M INTERSEX |
| emergencyContactFirstName | Emergency Contact First Name | Freetext (mandatory) | |
| emergencyContactLastName | Emergency Contact Last Name | Freetext (mandatory) | |
| emergencyContactPhoneNumber | Emergency Contact Phone Number | Freetext (mandatory) | |
| emergencyContactRelationship | Emergency Contact Relationship | Dropdown |
SPOUSEPARTNER PARENT CHILD SIBLING GRANDPARENT AUNTUNCLE NIECENEPHEW COUSIN FRIEND CARETAKER OTHER |
Trait Export
| Alias | Procedure | Question | Type | Options |
|---|---|---|---|---|
| crio-37905-277730 | Accessibility Needs | Do you have any accessibility needs or require adjustments for a visit to our clinical trial site? | SINGLE_SELECT | No | Yes |
| crio-37905-277737 | Accessibility Needs | If yes, please select | MULTI_SELECT | Accessible toilets | Assistance with navigation around the site | BSL interpreter | Quiet space | Step free access | Support with reading/writing forms | Other (please specify) |
| crio-37634-275418 | Smoking Status | What is your smoking status? | SINGLE_SELECT | Never smoked | Current smoker | Former smoker |
| crio-37891-277631 | Research Areas of Interest | Please select the research areas of interest to you | MULTI_SELECT | Allergies | Autoimmune disorders | Breathing, respiratory, or lung conditions | Cancer screening | Cholesterol | Chronic pain | Dementia | Diabetes, metabolic, or liver conditions | Eye disease | Heart disease/heart failure | Hypertension (blood pressure) | Other heart or circulatory conditions | Hair, skin, or nail conditions | Health screening | Kidney conditions | Men's health | Mental health conditions | Migraine or headaches | Muscle, joint, or bone conditions | Nerve or neurological disorders | Sleep disorders | Stomach conditions, or gastrointestinal conditions | Thyroid conditions | Urinary or bladder conditions | Vaccines | Weight related conditions (e.g. Obesity) | Woman's health |
| crio-20924-146204 | Demographics | Date of Birth | FREE_ENTRY | |
| crio-20924-146206 | Demographics | What is your sex? | SINGLE_SELECT | Male | Female |
| crio-20924-200349 | Demographics | Is the gender you identify with, the same as your sex registered at birth? | SINGLE_SELECT | Yes | No |
| crio-20924-275416 | Demographics | Preferred gender pronoun | SINGLE_SELECT | He/him | She/her | They/them |
| crio-20924-146207 | Demographics | What is your ethnic group? | SINGLE_SELECT | White | Mixed or multiple ethnic groups | Asian or Asian British | Black, African, Caribbean, or Black British | Other ethnic group | Prefer not to say |
| crio-20924-201028 | Demographics | Which of the following best describes your White background? | SINGLE_SELECT | English, Welsh, Scottish, Northern Irish or British | Irish | Gypsy or Irish Traveller | Roma | Any other White background |
| crio-20924-201029 | Demographics | Which of the following best describes your Mixed or Multiple ethnic groups background? | SINGLE_SELECT | White and Black Caribbean | White and Black African | White and Asian | Any other Mixed or multiple |
| crio-20924-201030 | Demographics | Which of the following best describes your Asian or Asian British background? | SINGLE_SELECT | Indian | Pakistani | Bangladeshi | Chinese | Any other Asian background |
| crio-20924-201031 | Demographics | Which of the following best describes your Black, African, Caribbean or Black British background? | SINGLE_SELECT | Caribbean | African | Any other Black, Black British, or Caribbean background |
| crio-20924-201032 | Demographics | Which of the following best describes your other ethnic group? | SINGLE_SELECT | Arab | Any other ethnic group |
| crio-41517-315930 | Height/Weight/BMI EMS | Height (cm): | FREE_ENTRY | |
| crio-41517-315931 | Height/Weight/BMI EMS | Weight (kg): | FREE_ENTRY | |
| crio-37901-277712 | Referral & Contact | Preferred methods of communication? | MULTI_SELECT | Email | SMS (Text) | Phone |
| crio-37901-277719 | Referral & Contact | How did you hear about us? | SINGLE_SELECT | Community event | EMS Healthcare mobile unit | EMS Healthcare website | Letter or SMS (text) from doctor | Printed advert (e.g. poster) | Radio advert | Social media (e.g. Facebook) | Word of mouth | Other (please specify) |
| crio-20926-146212 | Medical History | Finding | FREE_ENTRY | |
| crio-20926-146213 | Medical History | Start | FREE_ENTRY | |
| crio-20926-146214 | Medical History | Stop | FREE_ENTRY | |
| crio-20927-146215 | Concomitant Medications | Medication | FREE_ENTRY | |
| crio-20927-146216 | Concomitant Medications | Reason | FREE_ENTRY | |
| crio-20927-146217 | Concomitant Medications | Start | FREE_ENTRY | |
| crio-20927-146218 | Concomitant Medications | Stop | FREE_ENTRY | |
| crio-20927-146219 | Concomitant Medications | Dose | FREE_ENTRY | |
| crio-20927-146220 | Concomitant Medications | Units | SINGLE_SELECT | milligrams (mg) | millileters (ml) | micrograms (ug) | per cent (%) | International Unit (IU) | ounce (oz) | other |
| crio-20927-146221 | Concomitant Medications | Route | SINGLE_SELECT | Oral | Topical | Subcutaneous | Transdermal | Intraocular | Intramuscular | Respiratory (inhalation) | Other |
| crio-20927-146222 | Concomitant Medications | Frequency | SINGLE_SELECT | Daily (QD) | Twice daily (BID) | Three times a day (TID) | As needed (PRN) | Other |