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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:
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Advanced Studies in Translational Research on Aging
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Updated: Thursday October 11, 2007