Clinical Trial Volunteer Form If you are interested in participating in one of our clinical trials, please fill out this form and forward to us by using the submit button below. We will respond to all inquiries via e-mail or telephone, whichever is preferred. We will use discretion so that your interest remains confidential. Thank you. First Name:   Last Name:   Sex:      Age:   Day Phone:      Evening Phone:   E-mail Address:   Best time to call:   Height:      Weight:   Have you ever participated in a clinical trial?  Yes   No If yes, when?   CLINICAL TRIALS: What studies are you interested in?   CURRENT MEDICATIONS: What medications are you currently taking?(including vitamins, prescriptions, herbal supplements) List medications here. MEDICAL HISTORY: Have you had any problems with the following (Check all that apply): 1.) Cardiovascular Chest pain High Blood Pressure Irregular Heartbeat Heart Disease 3.) Endocrine Thyroid Disease Diabetes 5.) Neurological Seizures Numbness or Tingling Paralysis Memory Loss/ Confusion Headaches/ Migraine Head Injuries 7.) Hematologic/Immune Anemia Blood Disease Swollen Glands Rheumatic Fever 9.) Hospitalizations Surgery Serious Injury List:________________ 11.) Hepatic/Bilary Hepatitis Liver Disease Gallbladder disease 2.) Psychiatric History Depression Anxiety Eating Disorder Suicide attempt Schizophrenia 4.) Respiratory Asthma Shortness of Breath Pneumonia Tuberculosis 6.) HEENT Ear Problems Vision Problems Eye Problems Mouth Problems Throat Problems 8.) Musculoskeletal Arthritis Gout Fractures Osteoporosis 10.) Genitourinary Kidney Disease Bladder Disease Incontinence Urinary Tract Infection 12.) Substance Abuse Alcohol Drugs Caffeine Other 13.) Cancer (List types): 14.) Do you smoke?Yes   No