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Patient Questionnaire/Information Request

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To get more information about volunteering for a clinical trial, please fill out the form below. Any information submitted will be encrypted for privacy and confidentiality. For more information, please see our Privacy/HIPAA page.


Name *
Address
City
State
Zip
Home Phone *
Work Phone
Cell Phone
Email *
Preferred method of contact *
Best time of day
to contact you *
Age (as of January 1, 2005)
Please check all that apply:

Arthritis
Cardiovascular Disease
Diabetes
    On Insulin
    On Insulin plus oral anti-diabetic medications
    On Metformin (Glucophage)
    On sulfonyurea (in Glucatrol, Amaryl, DiaBeta)
    On TZD's (such as Avandia or Actos)
    On more than one anti-diabetic medication
    Controlled by diet only
GERD (Gastroesophageal Reflux Disease)
High Blood Pressure
High Cholesterol
High Triglycerides
Irritable Bowel Syndrome
Nerve Involvement (neuropathy)
Kidney Disease
Obesity/Weight Loss
Osteopenia/Osteoporosis
Other (please specify)
Please list all prescription medications you are taking:
Please list all non-prescription (over the counter medicine) you are taking:
Please list your medical conditions and how long you have had them:
Do you have any other questions or concerns?

* Required fields

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