Appointment Tracking Form

Attachment 11

Agency for Toxic Substances and Disease Registry

Pease Study

Study ID No. |_________________|	Order Assigned by Coordinator	Comments	Completed			Clinic or In-field
			Date mm/dd/yy	Time hh:mm		0 clinic 1 home
Informed Consent	1.		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Update Contact Information	2.		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Blood Draw/ Urine Collection	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Assess Current Medication	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Body Measurements	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Blood Pressure Measurements	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Questionnaire	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Neurobehavioral Battery	[__]		|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1
Received Gift Card	9.	TOTAL AMOUNT RECEIVED: [___] $25 [___] $50 [___] $75 SIGNATURE:	|__|__|/|__|__|/|__|__|	|__|__|:|__|__|	AM PM	0	1