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Clinical Trials
 
 
         
 
Los Angeles
Clinical Trials - Sign Up Form

To determine if you qualify for a research study, we will ask you some questions about your medical history and present condition. This survey will remain confidential and will be reviewed by the research staff only. This information is for pre-screening purposes only and does not guarantee qualifications for a study. It may be kept on file for futire studies for which you may be eligible. If you do not qualify for a study or choose not to participate, at your request we will destroy the information submitted in this survey.
YES NO
Do you permit California Allergy and Asthma Medical Group to retain the information you submit on this form on file for future studies which you may be eligible?
PATIENT INFORMATION
*FIRST NAME:
*LAST NAME:
DATE OF BIRTH:
SEX:
*HOME PHONE:
ALT PHONE:
*EMAIL ADDRESS:
STREET ADDRESS:
CITY:
STATE: ZIP CODE:
 
MEDICAL HISTORY
SMOKING HISTORY: YES NO
  PACKS PER DAY
  NUMBER OF YEARS
  START DATE
  STOP DATE
MEDICAL CONDITION:
YES NO ASTHMA DIAGNOSIS DATE:
YES NO ALLERGIES DIAGNOSIS DATE:
YES NO COPD DIAGNOSIS DATE:
YES NO SINUSITIS DIAGNOSIS DATE:
YES NO PSORIASIS DIAGNOSIS DATE:
YES NO Ever been seen in the ER for asthma?
  DATE:
YES NO Ever been hospitalized for asthma?
  DATE:
YES NO Allergic reaction to any medication?
 
 
MEDICATIONS (Please list all medications. Include dose, regimen, and start date.)
ASTHMA MEDICATIONS:
ALLERGY MEDICATIONS:
OTHER MEDICATIONS/ MEDICAL CONDITIONS:
   
YES NO Are you willing to sign a medical release?

* Required Fields

 

 

 
 
 
     

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