Dysregulation of MicroRNA-181a-5p Targets TNFAIP3 to Promote MIF-CXCR4 Signaling and Immune Inflammatory Remodeling in Chronic Myeloid Leukemia

Participant Questionnaire Form Study Title: Dysregulation of miR-181a5p, TNFAIP3, MIF and CXCR4 in Chronic Myeloid Leukemia Patients Principal Investigator: Name: ______________________ Affiliation: ______________________ Phone / Email: ______________________ Participant Code (ID): _____________ Section 1: Demographic Information Age: ☐ 20–30 ☐ 31–40 ☐ 41–50 ☐ >50 Gender: ☐ Male ☐ Female Residence: ____________________________ Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed Educational Level: ☐ Primary ☐ Secondary ☐ Diploma ☐ Bachelor ☐ Higher Education Section 2: Medical History Do you have Chronic Myeloid Leukemia (CML)? ☐ Yes ☐ No Year of diagnosis: ___________ Current phase: ☐ Chronic ☐ Accelerated ☐ Blast crisis ☐ Not applicable Currently receiving treatment? ☐ Yes ☐ No Type of treatment: ☐ Imatinib ☐ Dasatinib ☐ Nilotinib ☐ Hydroxyurea ☐ Other: ___________ Previous TKI discontinuation? ☐ Yes ☐ No If yes, reason: ___________ Section 3: Symptoms and Clinical Information Symptoms (check all that apply): ☐ Fatigue ☐ Weight loss ☐ Night sweats ☐ Fever ☐ Bone pain ☐ Abdominal fullness ☐ Easy bruising ☐ None Chronic diseases: ☐ Diabetes ☐ Hypertension ☐ Thyroid disorder ☐ Autoimmune disease ☐ None ☐ Other: ___________ Section 4: Laboratory / Sample Information Was a blood sample collected? ☐ Yes ☐ No Date of sample collection: ___________ Fasting state: ☐ Yes ☐ No Blood transfusion in last 3 months? ☐ Yes ☐ No Infection last month? ☐ Yes ☐ No Section 5: Consent Confirmation Did you read and understand the information sheet? ☐ Yes ☐ No Do you voluntarily agree to participate? ☐ Yes ☐ No Permission to use your sample for ELISA/RT-PCR: ☐ Yes ☐ No Participant Signature: ____________________ Date: ____________ Researcher Signature: ____________________ Date: ____________