Women'S Interagency Hiv Study Oral Protocol Medical Evaluation Form printable pdf download

Women'S Interagency Hiv Study Oral Protocol Medical Evaluation Form

WOMEN'S INTERAGENCY HIV STUDY

ORAL PROTOCOL MEDICAL EVALUATION

FORM OP1

GENERAL INFORMATION

PARTICIPANT ID: ENTER NUMBER HERE ONLY IF ID LABEL IS NOT AVAILABLE

|__|- |__|__| - |__|__|__|__| - |__|

WIHS STUDY VISIT NUMBER:

FORM VERSION:

DATE OF INTERVIEW:

INTERVIEWER'S INITIALS:

|__|__| : |__|__|

TIME ORAL VISIT BEGAN:

AM ............... 1

PM ................ 2

INTRODUCTION: READ TO PARTICIPANT

Thank you for agreeing to participate in the oral component of the WIHS study. This is a very important aspect

of the WIHS study because we will learn more about women's oral health. I will need to ask you a few

questions about your medical history and oral hygiene. I understand that some of these questions may be

difficult for you to answer. Please take as much time as you need so I can gather information which is as

accurate as possible. Of course your responses will be kept confidential. Your name will not be reported to

anyone, or recorded on any form. We will use the same unique identification number that is used for the rest of

the study.

WIHS Oral Protocol Form OP1: Medical Evaluation - 10/01/98a

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Women'S Interagency Hiv Study Oral Protocol Medical Evaluation Form