Atlantic Life Sciences, Inc.

 



                     
       
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Participation form
Free & Informed Consent
 

Please complete the following form and provide accurate information.

                Demography and style of life
                                            *First Name:
*Birth date :
                                            *Last Name:
*Sex: Male Female
                                            *PhoneNo:
  E-mail:
                                                                                              Height
Inches or Meter
                                                                                             Weight:
pounds or Kilo
Which language do you speak, read and understand very well? French English Other
If Female, are you a menopausal woman? No If Yes, provide the date: or estimate in:
days, weeks, months or years
Have you ever smoked? No Yes
Have you stopped? No Yes
If Yes, please provide when have you stopped to smoke? estimate in: days, weeks, months or years
How many cigarettes are or were you smoking? / day or / week occasionally.
Have you donated any blood in the last 3 months? No Yes
Have you donated plasma in the last 10 days? No Yes
Are you vegetarian? No Yes
Can you drink milk or eat dairy products? No Yes
Any vegetables, meat, or any other food that you do not eat at all? No If Yes, please specify:
Do you have any history of allergy reaction to food, lotion, cream, medication, plants, animals, other)? No If Yes, please spcify:
Do you take any medication? No If Yes, provide the name:
Do you take any Over-the-Counter (OTC) product(s) or Vitamins? No If Yes, provide the name:
Since when are you taking that medication or OTC product(s)? Date: or for days, weeks, months or years.
Do you have any physical handicap?
(some handicaps do not prevent from participating)
No If Yes, please specify:
                      Experience with clinical studies
Have you been in a clinical study? No Yes
Do you have difficult veins? No Yes
If you are accepted in a study do you tolerate?

Catheter Repeated veni punctures None

When was your last participation in a clinical study?

Date: or for days, weeks, months or years.

Do not remember

What was the medication tested?
What was the amount of blood taken?

Please specify Milliliters
If Do not remember, was it:
between 50 and 499mL or more than 499mL.

      Medication history
When was your last visit to a physician?

Date
Do not remember.

Do you take any treatment on a regular basis?

No If Yes, please justify:

Have you taken any medication recently?

No
Yes, Specify the name (brands or generic names):
Yes, but you finished it, fill in the date in the date:

                                History of alcohol and drugs of abuse
Do you have an history of drug of abuse?

No If Yes, what is the frequency:
/ day / week / month / year or occasionally.

Do you have a history of alcohol abuse?

No If Yes, what is the frequency:
/ day / week / month / year or occasionally.

     Evaluation Health
Have you had any surgery? No If Yes, what kind of surgery:
Do you have any health problem with the following:
Asthma ? No Yes Bladder? No Yes

Bronchitis?

No Yes Cancer, Tumor? No Yes
Cardiovascular? No Yes Diabetes? No Yes
Eys/Ear/Throat/Neck? No Yes

Gastro Intestinal Tract?

No Yes
Gynecologic? No Yes Hepatitis? No Yes
? No Yes HIV? No Yes
Kidney? No Yes Liver/Pancreas/Spleen/ Gallbladder? No Yes
Lungs? No Yes Neurological? No Yes
Parkinson? No Yes Psoriasis? No Yes
Psychiatric? No Yes Rheumatism? No Yes
Thyroidis? No Yes Skin problem? No Yes
If othern specify:
             

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