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Thank you for your interest in Northern California Research. Please complete the brief questionnaire below to help us determine if you are pre-qualified for this study.
1
. Contact Information
Contact Information
Name:
Address:
City, State, Zip:
Phone Number:
Email Address:
Referred By:
2
. Age
Age
3
. Are you post menopausal? (Either natural or hysterectomy)
Are you post menopausal? (Either natural or hysterectomy)
Yes
No
I'm not sure
Are you currently taking some form of estrogen treatment?
4
. Please check all that apply to you.
Please check all that apply to you.
Diabetes I or II
Have Hypertension or are taking antihypertensives
High Blood Pressure
Smoke 10 or more cigarettes per day
Have high Cholesterol/or taking lipid-lowering medication
Have a documented history of heart problems (ie. stroke, heart attack, unstable angina, acute coronary syndrome, etc.)
None of the above.
5
. Please provide a list of any other medications that you are currently taking. Please be as specific as possible. Example: Metformin 500mg 2x/day for Diabetes.
Please provide a list of any other medications that you are currently taking. Please be as specific as possible. Example: Metformin 500mg 2x/day for Diabetes.
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