spss

1. www.project-redcap.org
Confidential
REDCap Demo Database (Longitudinal) - Drug Trial
Page 1 of 2
Demographics
Study ID __________________________________
Consent Information
Date subject signed consent __________________________________
(YYYY-MM-DD)
Contact Information
First Name __________________________________
Last Name __________________________________
Street, City, State, ZIP __________________________________
Phone number __________________________________
(Include Area Code)
E-mail __________________________________
Date of birth __________________________________
Age (years) __________________________________
Ethnicity
Hispanic or Latino NOT Hispanic or Latino Unknown / Not Reported
Race American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Unknown / Not Reported
Gender Female
Male
Has the patient given birth before? Yes
No
How many times has the patient given birth? __________________________________
Please provide the patient's weekly schedule for the activities below.
Monday Tuesday Wednesday Thursday Friday
Gym (Weight Training)
Aerobics
Eat Out (Dinner/Lunch)

2. www.project-redcap.org
Confidential
Page 2 of 2
Drink (Alcoholic Beverages)
Other information
Specify the patient's mood Very sad Indifferent Very happy
(Place a mark on the scale above)
Is patient taking any of the following medications? Lexapro
(check all that apply) Celexa
Prozac
Paxil
Zoloft
Height (cm) __________________________________
Weight (kilograms) __________________________________
BMI __________________________________
General Comments
Comments __________________________________