Recurrent Respiratory Papillomatosis Foundation

PATIENT SURVEY
PART 1

Survey Completion
0% 100%

This is a 4-part survey to update the RRP Foundation comprehensive epidemiological database of patient information. Your personal confidentiality will be maintained at all times. Your name, initials, birthdate, address, phone/fax/or e-mail address will not be included with any shared information. Only a unique numeric identifier will be assigned to distinguish responses.

The purposes of this survey are to:

  • Help provide health care information to patients and their families;
  • Provide key information to RRP researchers to help develop new treatments and prevention for RRP.
  • Parts of the survey may be included in a Ph.D. thesis to foster public support for RRP prevention, treatment and research.

The survey design is in 4 Parts:

  1. Patient History and Current Disease Status.
  2. Surgical/Adjuvant Treatment History.
  3. Voice Outcomes.
  4. Complications/Costs/Social-economic Issues.

An * indicates an answer is required.

May we share the above data in the unique identifier section for networking purposes when we create a patient/health care provider directory? * Yes
No
May we share your survey responses with RRP researchers? (if “Yes”, we may and if “No” we won’t.) * Yes
No
Is this the first time you are filling out this new, revised questionnaire? * Yes
No
If “no”, then how many times before have you completed the questionnaire? * 1
2
3 or more
If “no”, then when was the last time you completed the questionnaire? * 6 months ago
12 months ago
18 months ago
2 years or more
If “no”, then How many surgical procedures have you/your child undergone since the last completion of this questionnaire? * 0
1
2
3
4
5
>5
If “no”, then what types of procedures have you/your child had over the time period between completing the questionnaires? Check all that apply. * Office based
In the Operating room
If “no”, then what types of procedures have you/your child had over the time period between completing the questionnaires? *
Procedure date [mm/dd/yyyy]
1st2nd3rd4th5th
Pulsed KTP
CO2 laser
Microdebrider
“Debulking procedure” (ie any of first 3 choices) plus Cidofovir
“Debulking procedure” (ie any of first 3 choices) plus Avastin
“Debulking procedure” (ie any of first 3 choices) plus other