Clinical Research Questionnaire

The purpose of this Clinical Research Database questionnaire is to provide you with opportunities to participate in clinical research studies.  To download a full PDF version of this form, click here: Clinical Research Form

Personal and Contact Information
*Preferred contact method (select all that apply):
*Text Messages:
*Have you ever been seen or treated by a physician at Spectrum Medical?
*Have you ever participated in a clinical research study?
*Study Indication(s) that you are most interested in:
Acute Ankle SprainsAcute/Chronic Pain ConditionsDiabetesDyslipidemia/High CholesterolFibromyalgiaGoutHeart Attack PreventionHypertensionLow Back PainLupusMigraines/HeadachesObesityOsteoarthritisOsteoporosisRheumatoid ArthritisOther
In Case of Emergency Contact (Person Not Living in Your Household)
Patient History
Social History
*Relationship Status:
Smoking and Dietary History
*Have you ever used any tobacco products?
Type used? CigarettesCigarsPipeChewing tobaccoOther
*Are you on a special diet (i.e. low salt, low cholesterol, vegetarian)?
Reproductive Status
*Sex:
Some studies require that males with spouse/partner that is able to become pregnant, use an effective method of birth control while participating in the study. The study doctor must be informed if the partner becomes pregnant.
Spouse/Partner is potentially able to bear children.
Are you of child bearing potential?
Subject must agree to use systemic contraception (oral contraceptives, depo, implant, trandermally delivered (ortho Evra), IUD, vaginal contraceptive, or diaphragm plus spermicide; diaphragm plus male condom, or male condom plus spermicide).
Reason:
Surgical:

 

 

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Spectrum Medical Martinsville
1075 Spruce St, Martinsville, VA 24112
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