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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:
Email Address:
Referred By:
2
. Age
Age
3
. Are you currently taking 325mg of Aspirin?
Are you currently taking 325mg of Aspirin?
Yes
No
Sometimes
4
. Please provide a list of your current medications:
Please provide a list of your current medications:
5
. Please indicate if you have had any of the following cardio or cerebrovascular events:
Please indicate if you have had any of the following cardio or cerebrovascular events:
Heart Attack
Stroke
Transient Ischemic Attack
Angina (Chest Pains)
Peripheral Arterial Disease
Carotid Arterial Disease
Bypass
Stents
Other type of heart surgery
Other (please specify)
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