Clinical Trial Interest Form

Clinical Trial Interest Form

Clinical Diversity Solutions
Name

First NameLast Name
Date of Birth

MonthDayYear
Sex
Race/Ethnicity
Contact Number:
Format: (000) 000-0000.
E-mail
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any current medical conditions or diagnoses:
List any current prescriptions or medications:
Please indicate all studies that you would consider participating in:*

Alzheimer’s diseaseArthritisAsthmaBreast CancerCancerCervical cancerChronic kidney diseaseChronic obstructive pulmonary disease (COPD)DiabetesHeart diseaseHepatitisHigh cholesterolHIV/AIDSHypertension (High Blood Pressure)Liver diseaseLung cancerOsteopeniaOsteoporosisOvarian cancerProstate cancerRheumatoid ArthritisSickle Cell AnemiaStroke
Other
Additional Information
What is your health insurance coverage?
Do you currently have a primary care physician?
Do you have access to WiFi in your home?
Do you have easy access to a laptop or desktop computer?
In the last 30 days, has lack of transportation kept you from medical appointments?
In the last 30 days, has a lack of transportation kept you from attending social events (like going to church) or getting things needed for daily living (like shopping for groceries or clothes)?
Should be Empty: