Are you eligible for a research study?

Are you interested in our clinical research studies and want to see if you may qualify?

Please note that all information asked is kept confidential at all times and is only used to see if you will be eligible for a clinical research study.

Patient Information Form

Your Name:

Date of Birth:

Phone Number:

E-mail Address:

Do you have any of the following medical conditions?
Type II Diabetes
Hypertension (High Blood Pressure)
Chronic Back Pain
Chronic Knee or Hip Pain
Asthma
High Cholesterol
COPD (Chronic Obstructive Pulmonary Disease)
Gout

Please list what medications you are taking for the above
medical conditions. Please include daily dosage taken for each
medication:

Have you had any major surgeries in the past 5 years?
If yes, please list the type of surgery.

Have you been treated for any type of cancer in the past 5
years? If yes, please list the type of cancer and form of
treatment given.

Have you been involved in any other research studies in the
past 30 days?

1911 Douglas Blvd, Ste 85-238
Roseville, CA 95661
(Clinical Offices Located in Roseville and Sacramento, CA)
Hours of operation: Mon-Fri 7am-5pm
Phone: 916-780-0200
Fax: 916-780-1510
info@qcrtrials.com