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Healthy Seniors
A279 At least 65 years old in good overall health; 5 day, 4 night stay in our research dorm
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? Newspaper Radio Television Previous study Center watch Friend/Relative Other Please select one
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
