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NIA Clinical Studies--Recruitment Form

I want to participate ...

Please complete the following form and someone will contact you to provide you with additional information about NIA Clinical Research Studies. The information you provide will help us determine your eligibility. More information will be needed to complete the screening process. Participation is voluntary. To learn more about Clinical Research Studies at NIH click here.

Participation Questionnaire: (* Indicates required fields.)
First Name *
Last Name *
Street Address
City
State
Zip Code
Telephone No. *
Alternate Telephone No.
Email
Preferred Method of Contact	-Select- Preferred-Email Preferred-Telephone Preferred-Mail
Date of Birth
Gender	-Select- Male Female
Approximate Height
Approximate Weight
Ethnic Background	-Select- American Indian or Alaskan Native Asian or Pacific Islander Black, not of Hispanic Origin Hispanic Other or Unknown White, not of Hispanic Origin
Have you ever participated in a clinical trial?	-Select- Yes, within the past 3 months. Yes, but over 3 months ago. No, I have never participated.

Do you currently take any of the following types of medication? (Hold "Ctrl" key to select more than one.)

None antibiotics antihistamines anti-viral medications blood pressure medications cholesterol-lowering medications diabetes medication heartburn medications pain relievers steroids thyroid medications ulcer medications Other

What types of studies are you interested in? (Hold "Ctrl" key to select more than one.)

Any Studies Anemia Baltimore Longitudinal Study of Aging Blood Pressure Blood Vessel Function Bone Marrow Collection Cancer Diabetes Fast Food Genetics Healthy Volunteer Studies Men's Health, Low Testosterone Osteo- Arthritis White Blood Cell Donation

Would you like to be contacted about future studies? *

-Select- Yes No

How Did You Hear About Us?
Search Engine	(Please specify which one: Google, Yahoo, etc.)
Link from another Web Site	(Please specify which one: NIH Web site, Clinicaltrials.gov., Centerwatch.com, Craigslist, etc.)
Fair or Community Event	(Please specify which one.)
Print Ad	(Please specify which publication.)
Word of Mouth
Other
Comments:

NIA - ASTRA Unit Advanced Studies in Translational Research on Aging

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Updated: Thursday October 11, 2007