|
Experience
with clinical studies
|
| Have you been in a clinical
study? |
No
Yes
|
| Has anyone told you that it
is difficult to take blood from your veins? |
No
Yes
|
| If you are accepted in a study
and blood needs to be taken from you,what do you prefer? |
Catheter
To pick in vein
Other
|
| When was your
last participation in a clinical study? |
Specify the date:
(YYYY/MM/DD) , or
from
Days, or
from
Weeks , or
from
Months , or
from
Years , or
Do not remember
|
| Kind of medication taken |
|
| Amount of blood
taken |
Please specify
Milliliters
Do not remember
|
|
Medication
history
|
| When was your
last visit to a physician? |
Do not remember
Date
(YYYY/MM/DD)
|
| Do you take any
medication treatment on a regular basis? |
No
Yes, Date and reason:
|
| Have you taken
any medication recently? |
No
Yes, Specify the name of the medication (brands or generic
names):
Yes, but I have finished it, fill in the date in the next
section.
|
| When have you
stopped to take that medication? |
Specify the date:
(YYYY/MM/DD), or
from
Days, or
from
Weeks, or
from
Months, or
Do not remember
|
|
History
of alcohol and drugs of abuse
|
| Do
you have an history of drug of abuse? |
No
Yes, 1.what kind of drug:
2.what is the frequency?
|
| Do
you have a history of alcohol abuse? |
No
Yes, 1.what kind of alcohol:
2.How often do you drink?
|
|
Evaluation
Health
|
| Have you had
any surgery? |
No
Yes, what kind of surgery:
|
| Do you have any health problem with the following:
|
| Gastro Intestinal Tract? |
No
Yes |
Diabetes? |
No
Yes |
|
Eys/Ear/Throat/Neck?
|
No
Yes |
Heart? |
No
Yes |
| Blood Pressure? |
No
Yes |
Cholesterol? |
No
Yes |
| Thyroid? |
No
Yes |
Liver/Pancreas/Spleen/ Gallbladder?
|
No
Yes |
| Kidney? |
No
Yes |
Bladder? |
No
Yes |
| Lungs? |
No
Yes |
Asthma? |
No
Yes |
| Bonchitis? |
No
Yes |
Rheumatism? |
No
Yes |
| Skin problem? |
No
Yes |
Psoriasis? |
No
Yes |
| Psychiatric? |
No
Yes |
Neurological? |
No
Yes |
| Gynecologic? |
No
Yes |
Cancer, Tumor? |
No
Yes |
|
|
