Imagine Life with Controlled
Allergies and Asthma

CLINIC TRIALS

Los Angeles

Clinical Trials - Sign Up Form

We specialize in the diagnosis and management of asthma, allergy and clinical immunology including conditions such as allergic rhinitis (hay fever), sinusitis, atopic dermatitis (eczema), food allergy, drug allergy, anaphylaxis (systemic allergic reactions), contact dermatitis, urticaria (hives), angioedema (swelling), conjunctivitis, primary immunodeficiency syndromes and many others.

 
FUTURE STUDY ELIGIBILITY
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:
  Month Day Year
*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 (type "n/a" if not applicable)
  *NUMBER OF YEARS (type "n/a" if not applicable)
  *START DATE (type "n/a" if not applicable)
  *STOP DATE (type "n/a" if not applicable)
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 Nasal Polyps DIAGNOSIS DATE:
YES NO Ever been seen in the ER for asthma?
  DATE:
YES NO Ever been hospitalized for asthma?
  DATE:
YES NO Ever taken oral steroid tablets for asthma?
  TYPE:
YES NO Allergic reaction to any medications?
 
 
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