Clinical Trial Pre-Screening Application
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?
*
Please Select
Yes
No
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
What is your Gender?
*
Male
Female
Submit
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