Chronic Pain Clinical Trial
Subject Screening Form
Subject Information
Full Name
Date of Birth
Age
Gender
Female
Male
Other
Prefer not to say
Phone
Email
Address
Screening Questions
Primary Diagnosis
Pain Duration (months/years)
Pain Location(s)
Current Treatments/Medications
Suspected Cause/Etiology
Is the pain chronic (≥3 months)?
Yes
No
Is the subject willing to participate in the trial?
Yes
No
Eligibility Assessment
Meets Inclusion Criteria?
Yes
No
Meets Exclusion Criteria?
Yes
No
Notes/Comments
Staff Section
Staff Name
Screening Date
Eligible for Enrollment?
Yes
No