To determine if you are eligible for one of our research studies complete the questions below. Please note this is protected health information and you do not have to answer any questions you do not want to. Your answers will be kept confidential being used only for study screening purposes.

Name: __________________________________________________

Date: _______________________________________

Address:__________________________________________________ __

Telephone: (please check the # where we can leave a message)

(____)_________________________ (day)

(____)_______________________ (night)

(____)________________________(cell)

email: ________________________________________________________

MEDICAL HISTORY

Age:_________ Gender: (M / F)

Dateof Birth: __________________

Height:______________ Weight: _______________

CurrentPrior Medications:

(List any medications or supplements (including anything taken over the counter/herbals) that you take or have taken within the last year, the reason for taking them, and dates you started or stopped them.)

______________________________________________________

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______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

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Have you had any dose changes in the past 6 months to the above medications:_______________________________________

Do you have any drug allergies:___________________________

____________________________________________________________

Have you had any surgeries or procedures?_______________

Do you have a history of, or currently have any of the following Conditions, answer (Y) Yes or (N) No:

If (Y) Yes, please specify and indicate date of diagnosis.

___| ___ Diabetes?

___| ___ Heart Disease? (heart attack, arrhythmia, angina etc)

___| ___ Neurological Disorder (stroke, neuropathy, tremor etc)

___| ___ Cancer?

___| ___ High Blood Pressure?

___| ___ Kidney disease?

___| ___ Liver disease?

___| ___ Thyroid or other endocrine disease / hormone problem?

___| ___ Mental Health related issue? (depression, anxiety, bipolar disease, etc)

___| ___ Seizure disorder or head injury?

___| ___ AIDS / HIV +?

___| ___ Any other chronic condition?

If yes to any of the above, please specify and include dates of diagnosis, procedures and any pertinent information:_________________________________________________

_______________________________________________________________

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Are you capable of having children? Y / N

If YES, are you willing to use contraception? ____________________

Please indicate any contraception currently using: ________

______________________________________________________________

For Women only: are you pregnant / nursing or plan to become pregnant?_________

If NO, indicate the reason and date:

___Hysterectomy (date: __________)

___Vasectomy (date: __________)

___Tubal ligation (date: __________)

___Post‐menopausal (date of last menses :_________)

___Other (___________________________________)

Where did you hear about our research studies?

The Express

The Washington Post

Craigslist

Dr. Referral ____________________________

Patient Referral ________________________

Website

Flier

Other:___________________________________