Demography
and
style of life
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*First Name:
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*Birth
date : |
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*Last Name:
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*Sex: |
Male
Female |
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*PhoneNo:
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E-mail: |
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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:
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| 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:
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|
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.
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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:
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History
of alcohol and drugs of abuse
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| 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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