| *Last name |
: |
|
| *First name |
: |
|
| *Gender |
: |
Male
Female
|
| *Home address including postal
code |
: |
|
| E-mail address (optional) |
: |
|
| *Valid home phone # |
: |
|
| Other/ alternate phone # (optional) |
: |
|
| *What is the best time to contact you |
: |
Mornings
Afternoons
Evenings
|
| *Date of Birth |
: |
|
| *Current approximate height |
: |
Inches:
or Centimeters
|
| *Current approximate weight |
: |
Pounds:
or Kilograms
|
| *Ethnicity (Hispanic/Latino,
Asian, Black, White, Mixed Race) |
: |
|
| *Do you smoke (including occasional
smoking)? |
: |
Yes
No |
| If yes, how many cigarettes a
day/ week / month? |
: |
|
| *If no, have you ever smoked or used
tobacco products in the past? |
: |
Yes
No |
| If yes, when did you start and
date you quit |
|
|
| *Do you have a history of alcohol abuse or dependence (e.g. alcoholism)? |
|
Yes
No |
| If yes, please
specify date of last treatment |
|
|
| *Do you consume any alcohol containing products
? |
|
Yes
No |
| If yes, what type and how many
drinks a day/ week / month |
|
|
| *Do you have a history of drug
abuse or dependence? |
|
Yes
No |
| *Do you use or have you used illicit
or street drugs and/or any other drug
of abuse (eg. marijuana,
cocaine, hash) ? |
|
Yes
No |
| If yes, please provide the name of the illicit drug(s) and date of last use |
|
|
| *Are you taking any over the counter
medication (e.g. Aspirin, vitamins,
herbal/natural supplements, regular
Tylenol) ? |
|
Yes
No |
| If yes, please provide the name of the medication and date of last use |
|
|
| *Are you taking any prescription
medication (e.g. blood pressure medications,
cholesterol medications, antibiotics, sleeping pills, antidepressants)? |
|
Yes
No |
| If yes, please provide the name of the medication and date of last use |
|
|
| *Have you donated blood in the
last 56 days? |
|
Yes
No |
| If yes, please specify the date and the
amount of blood |
|
|
| *Are you participating / have you participated in any
other clinical trials elsewhere? |
|
Yes
No |
| If yes, when was the last study completed? |
|
|
| *How often do you participate in clinical
trials/studies (per year) ? |
|
|
| *Have you been ill
in the last 30 days? |
|
Yes
No |
| *Do you have difficulty swallowing
pills, capsules or liquid medications? |
|
Yes
No |
| *Are there any foods you will
not eat due to personal and/or religious
reasons? |
|
Yes
No |
| If yes, please specify |
|
|
| *Have you ever had any surgeries
of any kind (e.g. heart, kidney,
liver, bowel, bone fracture repair surgery) |
|
Yes
No |
| If yes, please specify the type and date of the surgery |
|
|
| *Do you have any allergies (e.g. food, drugs, environmental)? |
|
Yes
No |
| If yes, please specify including the type of
reaction |
|
|
| *Any presence or history of endocrine problems(e.g. diabetes) ? |
|
Yes
No |
| If yes, please specify |
|
|
*Any presence or history of
heart problems (e.g. low or high
blood pressure, angina)? |
|
Yes
No |
| If yes, please specify |
|
|
| *Any presence or history of respiratory
problem (e.g. asthma, bronchitis,
pneumonia, tuberculosis (TB))? |
|
Yes
No |
| If yes, please
specify |
|
|
| *Any presence or history of liver
problems (e.g. hepatitis B ,C, liver cirrhosis
) |
|
Yes
No |
| *Any presence or history of muscle
and/or bone problems (e.g. rheumatoid arthritis)? |
|
Yes
No |
| If yes, please specify |
|
|
| *Any presence or history of kidney and/or bladder
problems (kidney stones, urinary tract infection)? |
|
Yes
No |
| If yes, please specify |
|
|
| *Any presence or history of gastrointestinal
problems (e.g.
ulcer, gastritis, colitis, chronic diarrhea/ constipation, hemorrhoids)? |
|
Yes
No |
| If yes, please specify |
|
|
| *Any presence or history of psychiatric
and/or psychological disorders (e.g.
depression, anxiety)? |
|
Yes
No |
| If yes, please specify |
|
|
| *Any presence or history of neurological
disorders (e.g. migraines, epilepsy)? |
|
Yes
No |
| If yes, please specify |
|
|
| *Any presence or history of skin problems (e.g. eczema, psoriasis)? |
|
Yes
No |
| If yes, please specify |
|
|
| *Any presence or history of immunological problems (e.g. systemic lupus erythematosus)? |
|
Yes
No |
| If yes, please specify |
|
|
| *Any presence or history of hematological (blood) disorders (e.g. anemia? |
|
Yes
No |
| If yes, please specify |
|
|
| *Do you have any other medical conditions and/or health problems? |
|
Yes
No |
| If yes, please specify |
|
|
| *Do you agree for us to contact you for future study participation? |
|
Yes
No |
| FOR FEMALES
ONLY: |
|
|
| What is your reproductive status? |
|
Able to have children
Post- menopausal
Surgically Sterile
|
| If able to have children, is your menstrual cycle regular? |
|
Yes
No |
| If yes, please specify cycle days (e.g. 21, 28, 30) |
|
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| |
|
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| |
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