General Clinical Trial Application

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1. How did you learn about this study?

How did you learn about this study? Newspaper Radio	Flyer Presentation	Other - explain below.
Other (please specify)

2. Which of the following types of studies would interest you?
Weight loss / weight maintenance

Which of the following types of studies would interest you? Weight loss / weight maintenance Yes

No

3. Cholesterol Lowering?

Cholesterol Lowering? Yes

No

4. Blood glucose control / diabetes

Blood glucose control / diabetes Yes

No

5. Mental health / performance

Mental health / performance Yes

No

6. Are there other areas in which you would be interested?

Are there other areas in which you would be interested?

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7. The next part of this survey will ask specific health questions. Studies will have different qualifying criteria. If you would like your information kept on file to determine future eligibility, please check yes. Or, you may wait until the end of the survey to make your choice.

The next part of this survey will ask specific health questions. Studies will have different qualifying criteria. If you would like your information kept on file to determine future eligibility, please check yes. Or, you may wait until the end of the survey to make your choice. Yes

No

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8. Please enter your name and address.

Please enter your name and address. First Name:
Last Name:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:

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9. Telephone Numbers xxx-xxx-xxxx:

Telephone Numbers xxx-xxx-xxxx: Home Phone:
Work Phone:
Cell Phone:

10. Preferred Contact Number

Preferred Contact Number Home Phone

Work Phone

Cell Phone

11. Perferred time to call.

Perferred time to call. Morning

Afternoon

Evening

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12. Birthdate (mm/dd/yyyy)

Birthdate (mm/dd/yyyy) 2-digit Month (Jan=01)
2-digit Day (01, 15, etc.)
4-digit Year (yyyy)

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13. Gender

Gender Female

Male

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14. Marital Status

Marital Status Married

Divorced

Separated

Widowed

Never Married

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15. Race or Ethnicity:

Race or Ethnicity: American Indian / Alaska native

Asian

Black / African American

Hispanic

Not Hispanic or Latino

White

Decline / Don't know

*

16. Are you a US Citizen?

Are you a US Citizen? Yes

No

17. If you are not a US citizen, enter Visa number:

If you are not a US citizen, enter Visa number:

*

18. Enter height in feet and inches

Enter height in feet and inches Feet
Inches

*

19. Weight:

Weight:

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20. Do you have high blood pressure?

Do you have high blood pressure? Yes

No

Don't know

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21. Do you have a history of diabetes?

Do you have a history of diabetes? Yes

NO

Don't know

*

22. Do you have high cholesterol?

Do you have high cholesterol? Yes

No

Don't know.

*

23. Have you been diagnosed with cancer within the last five (5) years?

Have you been diagnosed with cancer within the last five (5) years? Yes

No

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24. Have you been diagnosed / treated for depression in the last six (6) months?

Have you been diagnosed / treated for depression in the last six (6) months? Yes

No

*

25. Do you have a history of tobacco use?

Do you have a history of tobacco use? Current

Former

Never

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26. How often do you drink wine, beer, or liquor?

How often do you drink wine, beer, or liquor? Never

Daily

Less than twice a month

Once a week

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27. List all prescription medications, over-the-counter meds, herbs, and supplement. If none, please enter 'none'.

List all prescription medications, over-the-counter meds, herbs, and supplement. If none, please enter 'none'. 1
2
3
4
5
6
7
8
9
10
11
12

28. For female participants only. Can you still have children?

For female participants only. Can you still have children? Yes

No

Don't know

29. If no, why?

If no, why? Post-menopausal Tubal ligation	Partial hysterectomy Complete hysterectomy	Infertility Other - Explain below.
Other (please specify)

1. Default Section

1. How did you learn about this study?

2. Which of the following types of studies would interest you?Weight loss / weight maintenance

3. Cholesterol Lowering?

4. Blood glucose control / diabetes

5. Mental health / performance

6. Are there other areas in which you would be interested?

7. The next part of this survey will ask specific health questions. Studies will have different qualifying criteria. If you would like your information kept on file to determine future eligibility, please check yes. Or, you may wait until the end of the survey to make your choice.

8. Please enter your name and address.

9. Telephone Numbers xxx-xxx-xxxx:

10. Preferred Contact Number

11. Perferred time to call.

12. Birthdate (mm/dd/yyyy)

13. Gender

14. Marital Status

15. Race or Ethnicity:

16. Are you a US Citizen?

17. If you are not a US citizen, enter Visa number:

18. Enter height in feet and inches

19. Weight:

20. Do you have high blood pressure?

21. Do you have a history of diabetes?

22. Do you have high cholesterol?

23. Have you been diagnosed with cancer within the last five (5) years?

24. Have you been diagnosed / treated for depression in the last six (6) months?

25. Do you have a history of tobacco use?

26. How often do you drink wine, beer, or liquor?

27. List all prescription medications, over-the-counter meds, herbs, and supplement. If none, please enter 'none'.

28. For female participants only. Can you still have children?

29. If no, why?

2. Which of the following types of studies would interest you?
Weight loss / weight maintenance