Questionnaire by US8mod

VIEWS: 8 PAGES: 4

									Baseline Questionnaire
(Please complete the entire questionnaire. This information will be kept confidential)

Name: ____________________________________
Bottle Number: _____________________________
E-mail: ___________________________________
Date: ___________________

1. How many days have you been sick with a cold in the last week?



2. Are you sick with a cold now?

Yes __           No __

3. If so, how would you rate the severity of your sickness on this scale?
(Please mark an “X” on the appropriate location)

         I-------------------------------------------------------------------------------------I

Just a sniffle                                                             The worst cold of my life


4. Do you use any cold preventatives? if so please list:
___________________
___________________
___________________
___________________


5. How many colds do you get in a year?
(Please circle the appropriate answer)

0-1              2-5               greater than five


6. Do you have any allergies to the following? (circle)
dairy                                 olive oil                                     sage
peanuts                               soy                                           onion
tree nut                              cayenne                                       parsley
eggs                                  wasabi                                        basil
wheat                                 citrus                                        eggplant
fish                                  horseradish                                   dandelion root
red peppers                           cumin                                         osha root
tomato                                peas                                          ginger
shellfish                             dill                                          vinegar
garlic                                glutin
Post-Study Questionnaire
(Please complete the entire questionnaire. This information will be kept confidential)

Name: ____________________________________
Bottle Number: _____________________________
Date: ___________________

1. How many days have you been sick with a cold in the last week?
_________

2. Are you sick with a cold now?

Yes __           No __

3. If so, how would you rate the severity of your sickness on this scale?
(Please mark an “X” on the appropriate location)

         I-------------------------------------------------------------------------------------I

Just a sniffle                                                             The worst cold of my life


4. Do you use any cold preventatives in the past week? if so please list:
___________________
___________________
___________________
___________________


5. How many colds do you get in a year?
(Please circle the appropriate answer)

0-1              2-5               greater than five

6. How often did you use the remedy administered in this study?

         Not at all
         1-3 times per week
         4-6 times per week
         7-10 times per week
         More than 10 times per week

7. Did you find this remedy to be effective in preventing or treating cold symptoms?

Yes __           No __
                                                                    THANK YOU, BE HEALTHY!
Instructions: Take ½ Tsp. (30 drops) twice a day. (Once in the morning and once at night.) Drops
can be mixed with water. DO NOT share this remedy with others.

If you have any questions, please contact a student from the Scientific Methods in Alternative
Medicine class, or contact Allison Turner (allisont@marlboro.edu; 579-6633cell)

We are conducting a study that is measuring the effectiveness of two remedies on the symptoms and
prevention of the common cold. You do not need to be sick to take part in this study. Please fill out
this form to insure that you are not allergic to anything that may be contained in either remedy.
Some of the allergies listed are not in the remedies. You will be asked to take this remedy twice a
day for five days and also to fill out a short survey related to your experience before and after the
five days. All information, including your name, will be kept fully confidential. Please take this
seriously and follow all the guidelines. THANK YOU, BE HEALTHY!




Instructions: Take ½ Tsp. (30 drops) twice a day. (Once in the morning and once at night.) Drops
can be mixed with water. DO NOT share this remedy with others.

If you have any questions, please contact a student from the Scientific Methods in Alternative
Medicine class, or contact Allison Turner (allisont@marlboro.edu; 579-6633cell)

We are conducting a study that is measuring the effectiveness of two remedies on the symptoms and
prevention of the common cold. You do not need to be sick to take part in this study. Please fill out
this form to insure that you are not allergic to anything that may be contained in either remedy.
Some of the allergies listed are not in the remedies. You will be asked to take this remedy twice a
day for five days and also to fill out a short survey related to your experience before and after the
five days. All information, including your name, will be kept fully confidential. Please take this
seriously and follow all the guidelines. THANK YOU, BE HEALTHY!




Instructions: Take ½ Tsp. (30 drops) twice a day. (Once in the morning and once at night.) Drops
can be mixed with water. DO NOT share this remedy with others.

If you have any questions, please contact a student from the Scientific Methods in Alternative
Medicine class, or contact Allison Turner (allisont@marlboro.edu; 579-6633 cell)

We are conducting a study that is measuring the effectiveness of two remedies on the symptoms and
prevention of the common cold. You do not need to be sick to take part in this study. Please fill out
this form to insure that you are not allergic to anything that may be contained in either remedy.
Some of the allergies listed are not in the remedies. You will be asked to take this remedy twice a
day for five days and also to fill out a short survey related to your experience before and after the
five days. All information, including your name, will be kept fully confidential. Please take this
seriously and follow all the guidelines. THANK YOU, BE HEALTHY!
Student Investigator Instructions:

1. Say what the study is about ("We are conducting a study that is measuring the
effectiveness of two remedies on the symptoms and prevention of the common cold.
You do not need to be sick to take part in this study.")

2. Ask them to fill out the baseline questionnaire.

3. Scan the allergies list, to ensure that the student can participate. There is a
highlighted copy of the allergies list available – do not show it to the participants.

4. If they don't have any of the highlighted allergies, pick the next bottle out of the
box, record the number of the bottle on the questionnaire, and give the bottle to the
participant.

5. Give the participant the "Instructions" sheet.

6. Ask them to check back in with you in five days (there will be a table out at lunch
and dinner) to return their bottle and fill out the post-test questionnaire.

7. Thank them for participating!

								
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