Effect of Monazite Sands in Patients With Osteoarthritis of the Knee
Phase: NA
Conditions: Osteo Arthritis Knee
Sponsor: University Vila Velha

 
 
Documente date: May  03rd, 2019
Effect of Monazite Sands in Patients with Osteoarthritis of the Knee   
Ethical committee Protocol No: 3.160.891     
 Screening_log  
 

        
SUBJECT SCREENING LOG 
____________________________________________________________________________________________________________ 
 
 
 
                           Page 1 of 2 
This template has been freely provided by The Global Health Network and was adapted 
to our. Reference: The Global Health Network when possible when using this template. 
www.theglobalhealthnetwork.org.  
 
Study brief Title: 
Effects of Sand Treatment on Osteoarthritis   
Official Title: Effect of Monazite Sands in Patients With Osteoarthritis of the Knee   
Ethical committee Protocol No:  3.160.891    
                         
Unique Protocol ID:   T015-M02-2019AF002                                         
 
Complete this log for every subject screened for inclusion in the study. 
 
Nº 
Subject’s name 
Gender 
Date of birth 
(dd/mm/yyyy) 
Date screened for 
eligibility 
(dd/mm/yyyy) 
Subject 
Eligible?1 
If ineligible, 
specify reason 
for ineligibility 
Investigator Initials 
and Date 
 
  
  
M Ο  F Ο  
  
  
(    ) Yes 
  
  
(    ) No 
  
  
M Ο  F Ο  
  
  
(    ) Yes 
  
  
(    ) No 
  
  
M Ο  F Ο  
  
  
(    ) Yes 
  
  
(    ) No 
  
  
M Ο  F Ο  
  
  
(    ) Yes 
  
  
(    ) No 
  
  
M Ο  F Ο  
  
  
(    ) Yes 
  
  
(    ) No 
  
  
M Ο  F Ο  
  
  
(    ) Yes 
  
  
  
(    ) No 
  
  
M Ο  F Ο  
  
  
(    ) Yes 
  
  
(    ) No 
1Legend: Inclusion Criteria: A) Joint pain related to daily activities; B) No morning joint stiffness greater than 30 minutes; C) Age between 30 and 95 years. 
 
 
Signature of the Principal Investigator: 
 
 
 
 
 
 
 
 
 Date: