fbpx

If you are experiencing illness or symptoms consistent with cold, flu, or COVID, or other illness, please wear a mask while in our clinic. If you are experiencing fever or chills, please reschedule your appointment after you have been symptom and fever free for at least 24 hours. Thank you for doing your part to keep those around you healthy and safe.

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:

     

     

    Spectrum Medical
    109 Bridge St, Danville, VA 24541
    Ph: 434-793-4711
    View Map & Directions

    Spectrum Medical Martinsville
    1075 Spruce St, Martinsville, VA 24112
    Ph: 276-790-3233
    View Map & Directions


    Make a Payment

     Appointment Request

     Email Us