Clinical Trial Pre-Screening

Clinical Trial Pre-Screening Application
Full Name*

First NameLast Name
Date of Birth*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Please a check mark beside all current and past medical conditions.*

AcneAcitinic Keratosis (Sun Spots)Acitinic KaratosisActive C-FifficileAllergic RhinitisAllergiesAlzheimersAnginaAnxietyArthritisAsthmaAtopic DermatitisBack PainBirth ControlBPHBronchitisBursitisCardiovascularC DifficileChronic PainColitisConstipationCOPDCOVID-19Crohn's DiseaseDepressionDiabetesDiverticulitisDyslipidemiaEczemaEndometriosisErectile DysfunctionFemale Urge IncontinenceFibromyalgiaFood RejectionGastrointestinal DisordersGlaucomaGoutHeart DiseaseHeart FailureHepatitisHigh Blood PressureHigh CholesterolHip PainHot FlashHypertensionInfectious DiseaseInfluenza / FluIrritable Bowel SyndromeKidney Disease / Diabetes 2Knee PainLower Back PainLow TestosteroneLupusMild Cognitive ImpairmentMigraineMultiple SclerosisNeuropathyNeutraceuticalsNocturiaNon-Alcoholic Fatty Liver / Diabetes 2ObesityOsteoarthritisOsteoporosisOTC SwitchOveractive BladderParkinson's DiseasePerpheral Vascular DiseasePeptic UlcerPneumoniaPost Herpetic NeuralgiaPostmenopausalPost Operative PainPsoriasisPsoriatic ArthritisPsychiatric DisordersPremature EjaculationProstate CancerRheumatoid ArthritisRosaceaSexual DisfunctionShoulder PainSinusitisSkin InfectionSleep DisordersSmoking CessationStrokeSun SpotsToe Nail FungusType 2 DiabetesUlcerative ColitisUrinary IncontinenceUrinary Tract InfectionsUrticariaUterine FibroidsVaginal AtrophyVaginal DrynessWrinklesWomen's HealthyYeast InfectionHealthy Subject
Please list any past surgeries.
Are you currently taking any medication?*

YesNo
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?*

YesNoNot 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?*

DailyWeeklyMonthlyOccasionallyNever
What is your Gender?*

MaleFemale
Should be Empty:

Clinical Trial Pre-Screening Application