ERCP Patient Questionnaire
Version Date: 2/18/2019 Subject ID __ __ __ __
Today’s date (month/day/year): __ __ / __ __ / __ __ __ __
Month/Year of your last ERCP: __ __ / __ __ __ __ (mm/year)
Person completing form: ________________ Interviewee relationship to patient: ____________________
Instructions:
Questions in this questionnaire (unless specified) relate to the time since your child last underwent an ERCP.
We will refer to this period as the “FOLLOW UP” period. Please answer the questions as best as you can.
• If you are the parent/guardian or of a child under 18 years old who is being invited to be in this study, the word
“you” in this document refers to your child.
• If you are a teenager who is being invited to be in this study, the word “you” in this document refers to you.
• If you are the legally authorized representative of a person who is being invited to be in this study, the word
“you” in this document refers to the person you represent.
1.1 During the FOLLOW UP period, have you ever admitted to the hospital (overnight or longer) for an attack of pancreatitis?
Yes No
Number of times since your last ERCP procedure: __________Date(s) _______________________
Number of times in your whole life: _____________ Date(s) _______________________
1.2 During the FOLLOW UP period, have you had an episode that you suspect was pancreatitis but you managed this at home, without a hospital admission?
Yes No
Number of times since your last ERCP procedure: __________Date(s) _______________________
Number of times in your whole life: _____________ Date(s) _______________________
IMPORTANT: Please DO NOT provide information on pain other than from pancreatitis.
2.1 Have you had pancreas abdominal pain since your last ERCP procedure?
Yes No
If ‘yes’, is the pain more or less frequent than before the ERCP intervention(s)?
Is the pain more or less severe than before the ERCP intervention(s)?
2.2 Have you experienced any of the following symptoms during the FOLLOW UP period?
vomiting How many episodes since your last ERCP procedure? ___________
diarrhea How many episodes since your last ERCP procedure? ___________
weight loss How much have you lost since your last ERCP procedure? _______________
Has there been a gain back of some of the weight loss? _______________
Page 1 of 2
1. Pancreatitis
2. Pain and Disability
Pediatric Follow-Up Patient Questionnaire CPDPC16-03
Version Date: 12/30/2016 Subject ID __ __ __ __ __ Subject Initials __ __ __
2.3 Do you overall feel that your pancreas symptoms are resolved/better/worse/unchanged since your last ERCP procedure?
resolve better worse unchanged
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