The Orlando Clinical Research Center

Liver

I 03
Research study to evaluate the safety and effectiveness of the investigational study medication when given with other medications indicated for the treatment of hepatitis C. 18 to 65 years old diagnosed with genotype 2 or 3 hepatitis C and not have received treatment for hepatitis C

Volunteer Information Contact Form

Please take a moment to complete the following medical history information so we can match you to the appropriate studies that you qualify for and may be interested in participating.

First Name:

Last Name:

Middle Initial:

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Home Phone

E-mail

How did you hear about us?

Do you Smoke? Yes No

Date of birth dd/mm/yyyy Male Female

Height Weight

List any allergies: List all current medications:

Do you have any medical problems in the following areas?
Please be detailed so we can better serve you.
Eyes, ears, nose or throat? e.g. glasses, hearing loss, sinusitis

Cardiovascular? e.g. High blood pressure, heart attack, chest pain, arrhythmias

Respiratory? e.g. asthma, emphysema, bronchitis, TB

Musculoskeletal? e.g. arthritis, gout, polio, fractures, cramping

Psychological? e.g. depression, anxiety, stress disorder

Genitourinary? e.g. bladder, cysts, prostate, UTI, impotence

Gastrointestinal? e.g. heartburn, hernia, diarrhea, gallbladder, constipation

Liver? e.g. hepatitis, jaundice, cirrhosis

Neurological? e.g. HIA's dizziness, fainting, sezures

Endocrine / Metabolic? e.g. diabetes, thyroid, cholesterol, obesity

Dermatological? e.g. rashes, hives, eczema, psoriasis, acne

Other? e.g. cancer, drug / alcohol abuse, herpes

Surgeries? e.g. tonsillectomy, appendectomy, hernia repair