MPA SAHPRA Data Capture Form

Name: [Insert patient name and surname] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of Birth: [Insert date of birth and/or ID number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of interview: [Insert date of interview in YYYY-MM-DD format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Interviewer: [Insert interviewer’s name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Language of interview: [Insert primary language used during interview] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient contact details: [Insert patient phone number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient email: [Insert patient email address] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Hospital where patient treated: [Insert hospital name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Groote Schuur Hospital folder number: [Insert folder number] (Only include if explicitly mentioned and if patient is confirmed to be treated at Groote Schuur Hospital; otherwise omit completely.) Have you ever used Depo-Provera / 3-month injection: [Insert Yes / No / Unsure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Are you currently receiving Depo medroxyprogesterone: [Insert Yes / No / Unsure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) When did you stop Depo: [Insert date or year stopped, or state currently still using] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) First Depo injection date: [Insert month and/or year of first injection] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Most recent Depo injection before diagnosis: [Insert date in YYYY-MM-DD format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Typical injection frequency: [Insert injection frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Total time on Depo: [Insert total duration on Depo] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Other hormonal contraception used: [Insert other hormonal contraception, hormone replacement therapy, implant, or none] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of other hormone treatment: [Insert date or year of other hormone treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Depo clinic card or prescription available: [Insert Yes / No / Will try] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Preferred way to share card or prescription: [Insert preferred method of sharing documentation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Other cancer diagnoses ever made: [Insert Yes / No and specify cancer types if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date when first meningioma symptoms started: [Insert date, month, or year] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) First or main symptoms: [Insert initial symptoms described by patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of meningioma diagnosis or first scan: [Insert date of diagnosis, first scan, or first surgery date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Which doctor diagnosed the meningioma: [Insert diagnosing doctor’s name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Tumour location if known: [Insert tumour location or state unknown if explicitly stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Has surgery ever been performed: [Insert Yes / No / Awaiting and include date, hospital, and surgeon if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Have you ever received radiotherapy for your meningioma: [Insert Yes / No / Awaiting] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Radiotherapy start date and centre: [Insert start date and treatment centre] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Most recent MRI or CT: [Insert most recent imaging type and location] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) When is the next MRI or CT booked: [Insert date, location, and booking clinician if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Current treating doctor for meningioma: [Insert treating doctors and associated hospitals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Next follow-up appointment date: [Insert next follow-up date in YYYY-MM-DD format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Ongoing symptoms now: [Insert current symptoms and brief description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Reported to SAHPRA as possible adverse event related to Depo: [Insert Yes / No and report date if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient wants us to report to SAHPRA: [Insert Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Consent to send SAHPRA radiology report and histology or proof of meningioma: [Insert Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Other: [Insert any other relevant information mentioned by the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include information if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, medical history, diagnoses, timelines, investigations, treatments, reports, or legal information. Use only the transcript, contextual notes or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely. Use as many lines or paragraphs as needed to accurately capture the documented information.)