Clinical Research Questionnaire

*First Name:

*Middle Name:

*Last Name:

Address:

City:

State:

Zip Code:

*Date of Birth:

Home Phone:

Work Phone:

Cell Phone:

*Text Messages: YesNo

*Email Address:

*Name of your Primary Physician:

Primary Physician Address:

*Primary Physician Phone:

*Have you ever been seen or treated by a physician at Spectrum Medical? YesNo

*Name:

Relationship:

*Home Phone:

*Please list any drug allergies/intolerance, as well as your reaction to the drug:

*Please list any past hospitalizations or surgeries:

*Your Occupation:

*Estimate weekly alcohol beverage use (beer, wine, mixed drinks):

*Estimate cups of coffee, tea, and/or colas per day: