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Questionnaire template

Clinical Trial Participation Consent (Patient consent 1)

Records contact details, medical history, understanding of the trial and the consent decision of prospective trial participants.

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Healthcare · Patient consent. All Healthcare templates

Questions in this template

About You

  1. Thank you for your interest in this clinical trial. This form records some details about you, checks that the trial has been explained clearly, and asks for your decision.

  2. What is your gender?

    Choose one:

    • Female
    • Male
    • Another gender
    • Prefer not to say

  3. How old are you?

    A number from 18 to 100

  4. What is your full name?

    Open answer

  5. What email address can the study team use to contact you?

    Open answer

Your Medical History

  1. Do you have a long-term illness?

    Choose one:

    • Yes
    • No
    • Prefer not to say

  2. Which illness do you have, and how is it currently managed?

    Condition: Shown when a long-term illness was reported

    Open answer

Understanding the Trial

  1. After the information session, do you feel you understand each of the following?

    • What the trial is trying to find out
    • What will happen to you during the trial
    • Possible risks and side effects
    • Possible benefits to you or others

    For each row: choose one:

    • Yes
    • Not sure
    • No

  2. Before deciding, please ask the study team to go over the points you do not yet understand.

  3. What questions or concerns do you have about the trial?

    Open answer

Your Decision

  1. Having considered the information, do you agree to take part in this clinical trial?

    Choose one:

    • Yes
    • No

  2. If you are willing, tell us what led you to decide not to take part.

    Condition: Shown when consent is declined

    Open answer