Xceed Clinical, Whitby, ON
Xceed Clinical trials
Xceed Clinical Volunteer Form
 
Xceed Clinical Volunteer Application form
VOLUNTEER APPLICATION
* Full Name:
* Gender:
* Address:
* Primary Phone Number:
Alternate Phone Number:
* E-mail:
Prefered Method of Contact:
Prefered time of Contact:
* Date of Birth:
Day
Year
* Current Height:
Inches
* Current Weight (in pounds):
* Ethnic Background:
Do you smoke (including occational smoking)?
Have you ever smoked or used tobacco related products in the past?
Do you have a history of alcohol abuse or alcohol dependancy (alcoholism)?
Do you consume alcoholic beverages?
Do you have a history of drug abuse or dependancy?
Have you ever used street drugs (eg. Marijuana, cocaine, ecstacy, etc.)?
Are you currently taking over-the-counter medication?
(ex. Aspirin, Vitamines, Herbal Suppliments, etc.)
If yes, please describe name of medication:
Are you currently taking any prescription medication?
(ex. Antidepressants, sleeping medications, birth control, etc.)
If yes, please provide name of medication:
Do you have any allergies? (ex. Food, drug, environmental)
If yes, please describe:
Heart desease / stroke
Diabetes
Asthma
Low or high blood pressure
Tuberculosis (TB)
Hepitatis A, B or C
Arthritis
Osteoperosis
Depression
Anxiety
ADHD
Migraines
Epilepsy
Eczema
Other (please specify below)
If Other, please specify:
Have you participated in any clinical research studies in the past year?
Have you been ill in the last 30 days?
Do you have difficulty swallowing a capsule, pills or liquid medications?
Do we have your permission to contact you for future studies?
Please enter the code:
(if you see Captial letters please enter them as Capitals)
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First
Last
Street Address Cont.
City
Province
Street Address
Postal Code
Feet
Month
Area Code
Phone Number

Health-related Behaviours/Medical History

Area Code
Phone Number
Do you have a history of any of the following conditions?
(please check all that apply)
Asian, Black, Hispanic, Mixes, White, etc.
Pounds
Thank you for your interest in participating in clinical trials. Please fill out the form below as accurately as possible, including all information marked with (*)
Personal information collected will be kept confidential and will be used only for the purpose it was collected.

General Information

Xceed Clinical, 1615 Dundas St. E, Unit 19, Whiby, ON 905-436-1600
XCEED CLINICAL • 1615 DUNDAS ST. E, UNIT 19, WHITBY, ON • info@xceedclinical.com • 905-436-1600
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