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.

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* 1. Prospective Patient's Name

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* 2. Contact Information

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* 3. Demographic Information

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* 4. Please list your current or past medical conditions or medical diagnoses. List only one diagnosis per line.

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* 5. Please indicate any medications you are currently taking as well as its purpose: (Ex. Metformin 500mg for Diabetes Type 2, Simvastatin 20mg for High Cholesterol)

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* 6. Diabetes Information

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* 7. Please if you've had a history of any of the following:

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