To Be Completed Before Registering Participant Into the Study

APPENDIX C: REGISTRATION FORM

To be completed before registering participant into the Study

PART A: IDENTIFICATION DETAILS

Consultant: ...... Hospital:......

Patient’s Surname: ...... Patient’s Forenames: ......

Patient’s title: Mrs Miss Ms Dr Other:...... Date of birth (dd/mm/yyyy): ...... /...... /......

Patient NHS No.: Patient hospital no.:

Patient’s address: ......

...... Postcode: ......

Patient’s daytime telephone number:...... Evening telephone number: ......

Mobile telephone number: ...... Patient’s email: ......

PART B: ELIGIBILITY

B(i) / Yes / No
Aged 16 or over / /
Referred to gynaecologist for unexplained Chronic Pelvic Pain / /
Has capacity to give consent /
Is able to speak English or has a suitable interpreter /
Is pregnant / /
Has had a hysterectomy / /

If any of the shaded boxes in section B(i) are ticked, the patient is not eligible. If the patient is eligible, proceed to section B(ii) to consider eligibility for the diagnostic test accuracy part of the study

B(ii) / Yes / No
Has identifiable cause of CPP on which treatment can be initiated without laparoscopy / /
Referred for laparoscopy / /
Requires MRI based on history and ultrasound / /

If all the clear boxes in both Sections B(i) and B(ii) are ticked, the patient is eligible for the diagnostic test accuracy part of the study. If all the clear boxes in section B(i) are ticked but one or more shaded box in B(ii) is ticked, the patient is eligible for data collection only.

Date of participant registration:

Has the patient been previously considered and consented for MEDAL (if yes, please use original Study No.)

PART C: STUDY REGISTRATION (COMPLETE AT THE TIME OF THE PHONE CALL ONLY)

To register please call 0800 953 0274

MEDAL study number:

MEDAL Contact name: ...... Telephone: ......

Date of laparoscopy, if known:

Protocol Version 2.0 - 5th September 2012