Detecting Breast Cancer Using Exhaled Breath
Subject # Date Age
Please answer these questions to the best of your ability. There are some questions you may be uncomfortable answering. Remember your name is not attached to this form and there will be no repercussions legal or otherwise. You may choose not to answer any questions without reprisal.
Pre-menopause Y N
Menopause Y N How many years? Smoker Y N Time of Last cigarette?
Marijuana Y N Time of last marijuana smoke
Past Smoker Y N When did you stop
Alcohol Intake Y N Time last had a drink
Current lung issues Y N Describe
Use of Inhaler Y N Last used Name of Inhaler Diabetic Y N
Dental infections? Y N Describe
Medications taken regularly; Please list: (over the counter and prescription)
Supplements taken today; Please list:
Any pain meds taken today? List
Last meal eaten: Time Eaten
What did you eat: ?
Last fluid taken: Time
What was the fluid/drink?
Anything else in mouth (gum, lozenges etc.) in the last 4 hours? List please.
VOLUNTEERS'S BILL OF RIGHTS
As an "experimental" or "research" subject you have the following rights:
Be told what the study is trying to find out.
Be told what will happen to you and whether any of the procedures, drugs, or devices is different from what would be used in standard practice.
Be told about the frequent and/or important risks, side effects, or discomforts of the research drugs, devices, or procedures.
Be told if you can expect any benefit from participating and, if so, what the benefit might be.
Be told the other choices you have and how they compare to being in the study.
Be allowed to ask any questions concerning the study both before agreeing to be involved and during the course of the study.
Be told what sort of medical treatment is available if any complications arise.
Refuse to participate at all or to change your mind about participation after the study is started. This decision will not affect your right to receive the care you would receive if you were not in the study.
Receive a copy of the signed and dated consent form.
Be free of pressure when considering whether you wish to agree to be in the study.