Skip to content
Askalot

← All Healthcare templates

Questionnaire template

Clinical Trial Participation Consent (Patient consent 2)

Records a clinical-trial candidate's basic details, health background, understanding of the trial and consent decision.

Preview

Healthcare · Patient consent. All Healthcare templates

Questions in this template

About You

  1. Thank you for considering our clinical trial. This short form records a few details about you, checks that the trial has been explained clearly and captures your decision.

  2. What is your gender?

    Choose one:

    • Female
    • Male
    • Non-binary
    • Prefer not to say

  3. How old are you?

    A number from 18 to 100

  4. What is your full name?

    Open answer

  5. Which email address should the study team use to reach you?

    Open answer

Your Health Background

  1. Do you live with any long-term (chronic) illness?

    Choose one:

    • Yes
    • No
    • Prefer not to say

  2. Which long-term illness or illnesses do you have, and how are they currently managed?

    Condition: Only for participants with a long-term illness

    Open answer

Understanding the Trial

  1. Following the information session, do you feel you understand each of these parts of the trial?

    • What the trial is trying to find out
    • What will happen to you during the trial
    • The possible risks and side effects
    • The possible benefits

    For each row: choose one:

    • Yes
    • Not sure
    • No

  2. Is there anything about the trial you would like to ask or that worries you?

    Open answer

Your Decision

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

    Choose one:

    • Yes
    • No

  2. Would you tell us why you have decided not to take part? (optional)

    Condition: Only for participants who declined

    Open answer