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:
- Patient History and Current Disease Status.
- Surgical/Adjuvant Treatment History.
- Voice Outcomes.
- 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?
* |
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