Clinical Trial Pre-Screening

Full Name *

First Name Last Name

Date of Birth *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email

example@example.com

Please a check mark beside all current and past medical conditions. *

Acne Acitinic Keratosis (Sun Spots) Acitinic Karatosis Active C-Fifficile Allergic Rhinitis Allergies Alzheimers Angina Anxiety Arthritis Asthma Atopic Dermatitis Back Pain Birth Control BPH Bronchitis Bursitis Cardiovascular C Difficile Chronic Pain Colitis Constipation COPD COVID-19 Crohn's Disease Depression Diabetes Diverticulitis Dyslipidemia Eczema Endometriosis Erectile Dysfunction Female Urge Incontinence Fibromyalgia Food Rejection Gastrointestinal Disorders Glaucoma Gout Heart Disease Heart Failure Hepatitis High Blood Pressure High Cholesterol Hip Pain Hot Flash Hypertension Infectious Disease Influenza / Flu Irritable Bowel Syndrome Kidney Disease / Diabetes 2 Knee Pain Lower Back Pain Low Testosterone Lupus Mild Cognitive Impairment Migraine Multiple Sclerosis Neuropathy Neutraceuticals Nocturia Non-Alcoholic Fatty Liver / Diabetes 2 Obesity Osteoarthritis Osteoporosis OTC Switch Overactive Bladder Parkinson's Disease Perpheral Vascular Disease Peptic Ulcer Pneumonia Post Herpetic Neuralgia Postmenopausal Post Operative Pain Psoriasis Psoriatic Arthritis Psychiatric Disorders Premature Ejaculation Prostate Cancer Rheumatoid Arthritis Rosacea Sexual Disfunction Shoulder Pain Sinusitis Skin Infection Sleep Disorders Smoking Cessation Stroke Sun Spots Toe Nail Fungus Type 2 Diabetes Ulcerative Colitis Urinary Incontinence Urinary Tract Infections Urticaria Uterine Fibroids Vaginal Atrophy Vaginal Dryness Wrinkles Women's Healthy Yeast Infection Healthy Subject

Please list any past surgeries.

Are you currently taking any medication? *

Yes No

If you are currently taking medications, please list them here. This includes any over-the-counter medications and supplements.

Do you have any medication allergies? *

Yes No Not Sure

Please list known allergies

Do you use or do you have history of using tobacco? *

Do you use or do you have history of using illegal drugs? *

How often do you consume alcohol? *

Daily Weekly Monthly Occasionally Never

What is your Gender? *

Male Female

Clinical Trial Pre-Screening Application