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?
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PATIENT INFORMATION
FIRST NAME:
LAST NAME:
DATE OF BIRTH:	MONTH JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YEAR 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
SEX:	MALE FEMALE
HOME PHONE:
ALT PHONE:
EMAIL ADDRESS:
STREET ADDRESS:
CITY:
STATE:	ZIP CODE:
MEDICAL HISTORY
SMOKING HISTORY:	YES NEVER
	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?