Pharmaceutical Clinical Trial Patient Survey Checklist
Ensure patient safety and data integrity with our Pharmaceutical Clinical Trial Patient Survey Checklist. Streamline feedback collection, identify areas for improvement, and enhance trial outcomes. Download now for a comprehensive guide to compliant and effective patient surveys.
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Patient Demographics
Collect basic patient information for statistical analysis and cohort identification.
Age (Years)
Gender
Race/Ethnicity
City of Residence
Date of Birth
Referring Physician (Optional)
Informed Consent & Study Understanding
Verify patient comprehension of the study purpose, procedures, risks, and benefits.
Have you read and understood the Study Information Sheet?
Please describe, in your own words, the purpose of the study.
Do you understand the potential risks and benefits of participating in this study?
Do you have any questions about the study procedures?
Date Informed Consent was Obtained
Patient Signature
Do you understand that you are free to withdraw from the study at any time?
Medication Adherence
Assess patient compliance with the assigned medication regimen.
Number of doses taken as prescribed yesterday
How often did you miss a dose yesterday?
Please explain any reasons for missed doses yesterday.
Date of last missed dose (if applicable)
Did you experience any difficulties taking your medication?
(If Yes) Please describe the difficulties you experienced.
Adverse Events Reporting
Capture details regarding any adverse events experienced during the trial.
Date of Adverse Event
Time of Adverse Event
Severity of Event (Mild, Moderate, Severe)
Detailed Description of Adverse Event
Event Duration (in minutes)
Body Areas Affected (Select all that apply)
Actions Taken to Address Adverse Event
Treatment Efficacy Assessment
Evaluate the perceived effectiveness of the treatment based on patient-reported outcomes.
Pain Level (0-10)
Overall Improvement Compared to Baseline
Describe any improvements you’ve experienced.
Severity of Symptom X (0-10)
How would you rate the effectiveness of the treatment?
Quality of Life (QoL) Impact
Measure the effect of the treatment on patient's overall quality of life.
Overall Quality of Life Score (0-100)
How has your energy level changed?
How has your mood been overall?
Sleep Duration (hours per night)
Please describe any changes you've noticed in your daily activities.
How would you rate your ability to perform household chores?
Study Satisfaction & Feedback
Gather patient opinions about their experience with the study process and research team.
Overall, how satisfied were you with your experience in this clinical trial?
On a scale of 1 to 10 (1 being not at all likely, 10 being extremely likely), how likely are you to recommend this clinical trial to others?
What did you like most about participating in this clinical trial?
What aspects of the clinical trial could be improved?
How would you rate the communication from the research team?
Do you have any additional comments or suggestions?
Protocol Compliance Verification
Confirm adherence to the study protocol throughout the trial duration.
Date of Last Medication Administration (as per protocol)
Number of Visits Completed (as per schedule)
Was fasting required prior to blood draws (as per protocol)?
Which procedures were performed during the last visit (as per protocol)?
Describe any deviations from the protocol observed or encountered.
Were all inclusion/exclusion criteria still met at the last visit?
Follow-up Visit Readiness
Ensure patient preparedness for scheduled follow-up visits.
Scheduled Follow-Up Visit Date
Scheduled Follow-Up Visit Time
Follow-Up Visit Location
Transportation Method to Visit
Estimated Travel Time (minutes)
Have you received appointment reminders?
Any concerns or questions for the next visit?
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