NHI Trial Eligibility Questionnaire

About NHI

The National Heart Institute (NHI) is a premier center of excellence for advanced cardiovascular care. NHI offers people at risk of cardiovascular disease and its complications the opportunity to participate in innovative clinical trials that can help improve their outcomes and provide high-level care. The National Heart Institute is uniquely positioned to participate in important medical discoveries to help narrow the treatment gap for patients and improve their outcomes. NHI’s clinical trials provide patients access to opportunities to improve their lives at no cost. All of the clinical trial protocols offered at NHI are registered with the United States government and approved by institutional review boards to provide patient safety and ensure the clinical trials deal with important health issues. NHI’s clinical trials offer equal access to everyone, for free, with no insurance requirements. If approved, trial patients may receive compensation for their participation.
Serving Los Angeles, California

NHI is located at 99 La Cienega Blvd # 203 Beverly Hills, CA 90211. At this time we accept only clinical trial candidates who are within driving distance of our Beverly Hills location. No insurance coverage is required and if you are accepted into one of our clinical trials, you may be eligible for compensation for your participation.
NHI Trial Eligibility Questionnaire

To see if you qualify and to help match you with one of the NHI clinical trials, please fill out and submit this form. Please answer as many of the questions as you can so that we can better determine your potential eligibility for a clinical trial. The information provided is confidential and NHI will safeguard it in a manner consistent with HIPAA rules. Our team will review your application and respond as soon as possible. Thank you.
Name*

First NameLast Name
Age*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What sex were you assigned at birth?
What is your race or origin? (Check one)

AsianBlack or African AmericanHispanic or LatinoNative American, Hawaiian or Other Pacific IslanderWhiteOther
YOUR HEALTH HISTORY
What cardiovascular/metabolic conditions have you been diagnosed with:
(Please list all you know about here.)
Do you have high blood pressure, or are you taking blood pressure medication?

YesNo
Do you have high cholesterol or being treated with cholesterol-lowering medication?

YesNo
Have you ever been diagnosed with heart failure?

YesNo
Have you ever been diagnosed with stiff heart syndrome (preserved function/HeFPEF)?

YesNo
Have you ever been diagnosed with weak heart syndrome (reduced function/HeFREF)?

YesNo
Have you ever experienced or been diagnosed with coronary or carotid artery disease (blockages in the arteries to your heart or brain?

YesNo
Have you had a heart attack?

YesNo
If yes, when was the most recent one?
Have you undergone coronary artery bypass surgery or coronary stent procedure?

YesNo
Have you had a stroke?

YesNo
If yes, when did it occur? (If more than once, please list the years):
Have you ever experienced or been diagnosed with peripheral artery disease (blockages in arteries to the legs) or found yourself developing calf pain with exercise and relief with rest?

YesNo
Have you had an angiogram test showing severe blockages in your coronary arteries?

YesNo
If you have had an angiogram test, what was the date and where was it performed?
Have you been diagnosed with type II diabetes?

YesNo
If yes, how many years have you had diabetes:
Have you been diagnosed with obesity or being overweight?*

YesNo
Have you been diagnosed with chronic kidney disease?*

YesNo
Have you been diagnosed with any cancer?*

YesNo
If you have been diagnosed with cancer, what type?
If yes, when was the cancer diagnosed?
What year did you complete your most recent cancer treatment?
Have you been diagnosed with HIV?

YesNo
Your Health Information

(We understand you may not be able to provide all this information, but please submit as much as you can.)
Height:

feetinches
Weight:
lbs
Most recent blood pressure (systolic/diastolic):

systolicdiastolic
Most recent blood creatinine level:
Most recent LDL cholesterol:
Triglycerides
Most recent A1C blood test level if diabetic
Most recent BNP or NT Pro-BNP level

List of current medications you take and doses, if known:

	Medication	Dose
1
2
3
4
5
6
7
8
9
10

Are you allergic to any medications? If so, please list them here

	Medication
1
2
3

Do you ever experience:
Chest discomfort with effort or activity that is relieved by resting.

YesNo
Shortness of breath with effort, such as walking uphill, is relieved by resting.

YesNo
Swelling of your ankles and/or lower legs.

YesNo
Calf pain with activity relieved with rest.

YesNo
Are you currently a smoker?

YesNo
If you are currently smoking, how many cigarettes (or packs) per day?
If you smoked in the past but are not currently smoking, approximately how many packs per day on average and for how many years?
If you smoked in the past but are not currently smoking, approximately how many packs per day on average and for how many years?

Packs per day on averageFor how many years
Do you consume alcoholic beverages?

YesNo
Do you consume alcoholic beverages?

10 or more drinks per week6-9 drinks per week2-5 drinks per weekOne drink or less per week
Do you currently have or have a history of substance abuse?

YesNo
If YES, please briefly describe the substance and the time period you took it.

SubstancePeriod
Do you have a family history of heart attack, stroke bypass surgery, or stent placement in a parent or sibling?

YesNo
TRIALS
What trials are you most interested in participating in? (Please select as many as you want.)

Coronary artery diseaseHeart attack and/or stroke prevention for those with a history of such in the pastCholesterol disordersHeart failure preventionHeart failure treatmentObesityType II DiabetesChronic kidney diseaseHigh blood pressure
Do you prefer to be contacted via email or phone?

EmailPhone
Your Primary Care Physician
Name
Address
Phone Number
Please enter a valid phone number.
Your Emergency Care Contact
Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to you
CLINICAL TRIAL/SCREENING CHECKLIST
If you are accepted for a clinical trial screening, it's important that you secure and bring the following to your first visit:
- Medical records from your most recent doctor visit
- Most recent blood test results
- Your medication bottles and a complete list of what you take, dose, and frequency
Send this form electronically by clicking on the SUBMIT button below.

Alternatively, you can print out the form and send it to:

National Heart Institute
99 La Cienega Blvd # 203
Beverly Hills, CA 90211

By sending this form to NHI you certify that the information you have provided is accurate to the best of your knowledge and you accept NHI's Terms and Privacy policies.
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About NHI

Serving Los Angeles, California

NHI Trial Eligibility Questionnaire

YOUR HEALTH HISTORY

Your Health Information

TRIALS

Your Primary Care Physician

Your Emergency Care Contact

CLINICAL TRIAL/SCREENING CHECKLIST