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Enrollment item set:-:Pt:^Patient:-:ADAPTABLE
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Early visit item set:-:Pt:^Patient:-:ADAPTABLE
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Follow-up visit item set:-:Pt:^Patient:-:ADAPTABLE
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Aspirin usage^post enrollment in ADAPTABLE study:Find:Pt:^Patient:Ord:ADAPTABLE
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Address
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Medication allergy Reported
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Hx of Severe bleeding due to aspirin use
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Aspirin dose^post enrollment in ADAPTABLE study:Mass:Pt:^Patient:Qn:ADAPTABLE
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mg
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Phone #
?
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Willing to change aspirin dose:Find:Pt:^Patient:Ord:
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Enteric coated aspirin
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Permission text messages
?
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Reason for discontinuing aspirin use:Find:Pt:^Patient:Nom:
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Social Security #
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Anticoagulant med used
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Date aspirin discontinued
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{mm/dd/yyyy}
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Secondary contact name
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Pregnancy status
?
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Contact Phone #
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Breastfeeding status
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Blood thinning med used
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Health self assess
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Contact email address
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NSAID used several times a week
?
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Race
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Stomach upset meds
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Are you able to run errands and shop:Find:Pt:^Patient:Ord:PROMIS
©
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Hispanic or Latino
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Hospitalization^post enrollment in ADAPTABLE study:Find:Pt:^Patient:Ord:ADAPTABLE
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I felt depressed in past 7D:Find:7D:^Patient:Ord:PROMIS
©
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Hospital Name
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Medicare enrollment status:Find:Pt:^Patient:Nom:
?
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I feel fatigued during the past 7D:Find:7D:^Patient:Ord:PROMIS
©
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Primary insurance
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Address:Addr:Pt:Facility:Nom:
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I had a problem with my sleep 7D:Find:7D:^Patient:Ord:PROMIS
©
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I have trouble doing all of my regular leisure activities with others in the past 7D:Find:7D:^Patient:Ord:ADAPTABLE
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Ins group num
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Admission date
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{mm/dd/yyyy}
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Pt ID
?
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Reason for hospitalization
?
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How much did pain interfere with your day to day activities in past 7D:Find:7D:^Patient:Ord:PROMIS
©
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Events^during hospitalization:Find:RptPeriod:^Patient:Nom:ADAPTABLE
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Satisfaction with using ADAPTABLE web site:Find:Pt:^Patient:Ord:ADAPTABLE
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Pt ID assign auth
?
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Adequacy of information on+time spent reading ADAPTABLE web site:Find:Pt:^Patient:Ord:ADAPTABLE
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Current smoker
E
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Patient name
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Aspirin usage^pre enrollment in ADAPTABLE study:Find:Pt:^Patient:Ord:ADAPTABLE
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Sex
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Year aspirin regimen began
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{yyyy}
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Birth date
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{mm/dd/yyyy}
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Aspirin dose^pre enrollment in ADAPTABLE study:Mass:Pt:Dose:Qn:ADAPTABLE
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mg
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Aspirin usage^post enrollment in ADAPTABLE study:Find:Pt:^Patient:Ord:ADAPTABLE
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Aspirin dose^post enrollment in ADAPTABLE study:Mass:Pt:^Patient:Qn:ADAPTABLE
|
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mg
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|
Enteric coated aspirin
|
|
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Reason for discontinuing aspirin use:Find:Pt:^Patient:Nom:
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Date aspirin discontinued
|
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{mm/dd/yyyy}
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Blood thinning med used
|
|
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NSAID used several times a week
?
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Stomach upset meds
|
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Hospitalization^post enrollment in ADAPTABLE study:Find:Pt:^Patient:Ord:ADAPTABLE
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Hospital Name
|
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Address:Addr:Pt:Facility:Nom:
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Admission date
|
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{mm/dd/yyyy}
|
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Reason for hospitalization
?
|
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Events^during hospitalization:Find:RptPeriod:^Patient:Nom:ADAPTABLE
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