UNIVERSITY OF ALEXANDRIA

HIGH INSTITUTE OF PUBLIC HEALTH

IN COLLABORATION WITH
FACULTY OF MEDICINE
A PROTOCOL DEVISED BY UNIVERSITY OF MANCHESTER
FUNDED BY THE SCIENCE AND TECHNOLOGY DEVELOPMENT FUND
)(STDF

PROJECT NAME: 5HTT- GENE POLYMORPHISM AS A PROGNOSTIC INDICATOR IN CANCER

PROJECT ACRONYM: ICIC-1
STDF Project ID: 225
Project PI: Dr. Noha Awad

:
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UNIVERSITY OF ALEXANDRIA
HIGH INSTITUTE OF PUBLIC HEALTH
IN COLLABORATION WITH
FACULTY OF MEDICINE
A PROTOCOL DEVISED BY UNIVERSITY OF MANCHESTER
FUNDED BY THE SCIENCE AND TECHNOLOGY DEVELOPMENT
)FUND (STDF

:
,

. 0112287247
. 0101440445

UNIVERSITY OF ALEXANDRIA
HIGH INSTITUTE OF PUBLIC HEALTH
IN COLLABORATION WITH
FACULTY OF MEDICINE
A PROTOCOL DEVISED BY UNIVERSITY OF MANCHESTER
FUNDED BY THE SCIENCE AND TECHNOLOGY DEVELOPMENT
)FUND (STDF

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Appendix 9: Data collection forms

HIGH INSTITUTE OF PUBLIC HEALTH

IN COLLABORATION WITH
FACULTY OF MEDICINE
PROJECT NAME: UTILZATION OF 5HTT- GENE AS A PROGNOSTIC
INDICATOR IN CANCER PROJECT ACRONYM: ICIC-1
STDF Project ID: 225 Project PI: Dr. Noha Awad

Data Collection Sheet

Baseline patients characteristics
( Please ensure patient name and date on every sheet)
Study code...........................

Date

Patient Name ...........................................................................................................................................

Sex

M/F

DOB.....................................

Age.........................................................(years)

Address
Phone number.........................................................../
Recruitment Centre.

Hospital Number..................................................

Consultant...................................................... Recruiting Doctor

Clinical information
Diagnosis ................................................
Primary Tumour Size Nodal Involvement 1 = yes 2 = no 3 = no information
Stage (TNM or cancer site-specific staging )
Extent of disease 1 = primary local, 2 = locally advanced 3 = metastatic

Sites of metastatic disease

lung
bone
liver

1 = yes 2 = no brain
1 = yes 2 = no lymph
1 = yes 2 = no other

1 = yes 2 = no
1 = yes 2 = no
1 = yes 2 = no

Number of sites of metastatic disease 0 = none 1 = one 2 = two or more

Current Treatment: Tick all that apply

Chemotherapy

Radiotherapy

Surgery

Hormonal treatment

Biological therapy

Planned subsequent Treatment: Tick all that apply

Chemotherapy

Radiotherapy

Surgery

Hormonal treatment

Biological therapy

HIGH INSTITUTE OF PUBLIC HEALTH

IN COLLABORATION WITH
FACULTY OF MEDICINE
PROJECT NAME: UTILZATION OF 5HTT- GENE AS A PROGNOSTIC
INDICATOR IN CANCER PROJECT ACRONYM: ICIC-1
STDF Project ID: 225 Project PI: Dr. Noha Awad

Sociodemographic patients characteristics

( Please ensure patient name and date on every sheet)
Study code...........................

Date

Patient Name ...........................................................................................................................................

Marital status
married
separated / divorced
widowed
single

Employment Status

working full time (more than 30 hours per week)

working part time (less than 30 hours per week)
unable to work due to illness / disability
retired
at home and not looking for paid employment (e.g. looking after your home, family or
other dependants
unemployed and looking for work
student
other

Education

illiterate
can read and write
primary school
middle school
high school
university
postgrad
other

. / .
/ .
. .
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________________________________________________________ :

_______________ :

)(HADS

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:
) (HADS R.P. Snaith.1994 1992 1983 A.S. Zigmond
" 70-361 67 " Acta Psychiatrica Scandinavica
.1983 Copenhagen Munksgaard International Publishers Ltd
1994 . London W4 5TF 414 Chiswick High Road nferNelson Publishing Company Ltd
GL Assessment . Granada Group
.
permissions@gl-assessment.co.uk :

HADS - Egypt/Arabic - Version of 16 Oct 09 - Mapi Research Institute.

ID5470 / HADS_AU2.0_ara-EG.doc

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Watson, M. and Awad, N. 2011.