Demographics

Participant’s code ………………………………

Please tick the answer that suits you most or write in the empty space if you
consider it necessary.

1) Sex

Male

Female

Other

2) Age ……………..

3) Status
…………………………………………………………………………….

4) Diagnosis
……………………………………………………………………….

5) Treatment
………………………………………………………………………..

6) Duration of treatment
…………………………………………………………..

7) Have you taken medication during your treatment?

Yes

No

8) If yes, please describe medication and dosage

……………………………

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