XCEED CLINICAL - Volunteer Application

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)

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, WHITBY, ON • info@xceedclinical.com • 905-436-1600