Noble Clinical Research Medical Form

About Noble Clinical Research: "Where the Doctor Pays You™"Here at Noble Clinical Research, we pay you for every visit if you fully qualify and participate in a research study. Our studies usually pay you between $400 and $8,000+ over the course of the study. Everything on the study is of no cost to you. This can include free medical exams, bloodwork, medicines, investigational drugs, and more. It's all free to you, no matter what. You don't need or have to involve health insurance. Plus, our clinical research can give you access to next-generation, investigational potential treatments. In general, the only way for you to get access to those treatments is to join research studies with us or other clinics. Dr. Petersen recently went on Tucson's local TV show, The Morning Blend, to teach Tucsonans about the benefits of high-paying clinical trials with us!

Name* This field is required.

First Name

Last Name

Please enter your phone number, including your area code.* This field is required.

Phone Number* This field is required.We will text you or call you at this number.

Area Code

Phone Number

Email* This field is required.We will never sell your email. Email is used as a backup method in case we can't get in touch with you by texting or calling.

example@example.com

Monthly emails about our new studies that pay you* This field is required.We will never sell your email address. To opt out of monthly email updates, click on the button below “Not now, maybe later”, and we will only email you if we identify a specific study you may qualify for based on your responses to this questionnaire.

YES, I'M IN! Please add me to your mailing list about future studies that can pay me.NOT NOW, MAYBE LATER. (I understand I may miss out on new studies)

Please choose your sex.* This field is required.

Male

Female

Please enter the year that you were born.* This field is required.Many research studies have a defined age range for participants.

Please share the feet component of your height.* This field is required.E.g. if you were 5'10", you would only type 5 into this box. You would NOT type in 5-10, or anything like that. (You'll type the inches component in the next page).

Please enter the feet component of your height (e.g. if you are 5'10", type 5)

Please share the inches component of your height.* This field is required.E.g. if you were 5'10", you would only type 10 for 10 inches into this box. (You already typed in the feet component on the previous page).

Please enter the inches component of your height (e.g. if you are 5'10", type 10)

Please tell us your weight in pounds.* This field is required.

Do you live in the Tucson area year-round, or are you a "snowbird"/seasonal resident?* This field is required.Snowbirds might still be able to join shorter clinical trials, but many trials last over six months.

YES, I live in the Tucson area year-roundNO, I don't live here year-round, I'm a snowbird/seasonal

Do you have any of the following lung health conditions?* This field is required.Check any and all that you have.

Asthma

COPD (Chronic Obstructive Pulmonary Disease)

Emphysema

Chronic Cough

Seasonal Allergies

(None of the above)

Do you have any of the following Heart/Cardiovascular health issues?* This field is required.

High blood pressure

High cholesterol

Coronary Artery Disease

History of Heart Failure

History of Heart Attack

None of the above

Do you have any of the following sleep-related conditions?* This field is required.

Shift-work Sleep Disorder (if you work night shifts)

Insomnia

Sleep Apnea

Narcolepsy

Restless Leg Syndrome 🦵😵

Excessive Daytime Sleepiness 😴

(No sleep issues)

I see you currently have sleep apnea. Do you currently use a "PAP" (CPAP or BiPAP) mask device for your sleep apnea?

Yes, I still use a BiPAP or CPAP mask on a regular basis for my sleep apnea.

No, I used to use a CPAP or BiPAP mask, but no longer.

I've never used a CPAP or BiPAP mask, but I still have sleep apnea.

Hypoglossal nerve stimulator (for example, Inspire)

Do you have any of the following gastrointestinal conditions?* This field is required.

Irritable Bowel Syndrome

Crohn's Disease

Ulcerative Colitis

Celiac Disease

Gastroesophageal Reflux Disease (GERD)

Gastroparesis

Exocrine Pancreatic Insufficiency

(None of the above)

Liver ConditionsDo you have any of these?

NASH/MASH (Non-Alcoholic Steatohepatitis)/Non-Alcoholic Fatty Liver Disease

Cirrhosis of the Liver

(None of the above)

Do you have any of the following metabolic health conditions?* This field is required.

Overweight/Obesity/I'm interested in weight loss studies

Type 1 Diabetes Mellitus

Type 2/II Diabetes Mellitus

Prediabetic

None of the above

Do you have Diabetic Peripheral Neuropathy? * This field is required.This is where diabetes interferes with your circulation, causing painful sensations in your feet/legs and hands/arms. Painful sensations can include "pins and needles", "burning", "tingling", etc.

YES, I have Diabetic Peripheral Neuropathy.

NO, I don't have Diabetic Peripheral Neuropathy.

Do you have any of the following Women's Health conditions?Any interest in studies for any of the following?

Hot flashes/vasomotor symptoms of menopause

Heavy menstrual bleeding

Endometriosis

Dyspareunia (painful sex)

Uterine Fibroids

Polycystic Ovary Syndrome (PCOS)

Infertility

Amenorrhea

(None of the above)

Are you currently pregnant or breastfeeding?

YESNO

Men's health studiesAny interest in studies for any of the following?

Prostate health/Benign prostatic hyperplasia/Enlarged prostate

Low testosterone/hypogonadism

(None of the above)

Do you have any of the following neurologic conditions?

Non-Migraine Headaches

Migraines

Alzheimer's

Epilepsy/seizures

Recent stroke/stroke recovery

Memory loss

Traumatic Brain Injury

(None of the above)

Do you have any of the following "itchy" skin conditions?* This field is required.

Plaque Psoriasis/Psoriasis

Atopic Dermatitis/Eczema

Chronic Spontaneous Urticaria

Hidradenitis Suppurativa

Lichen Simplex Chronicus

None of the Above

And how about these other skin conditions?* This field is required.

Acne

Rosacea

Vitiligo

Cutaneous Lupus Erythematosus

(None of the above)

Do you currently have any of the following chronic infections that you would be interested in a treatment study for?* This field is required.

HIV

Hepatitis B

Hepatitis C

Herpes/HSV (including cold sores and genital)

Tuberculosis

Long COVID

Lyme Disease

(None of the above)

Would you be interested in studies of investigational vaccines to see if they protect against illnesses?* This field is required.We may get studies of vaccines that may protect against viruses like COVID, herpes, flu, RSV, and more. However, some people do not currently wish to take vaccines, and we always respect each person's individual preferences.

YES, POTENTIALLY. Please reach out to me about preventative vaccines.NO THANKS, I'm not interested in vaccines at this time.

Would you be interested in research studies of "non-vaccine prophylactics" for patients at high risk of complications from respiratory diseases such as COVID, flu, and RSV?These are often monoclonal antibodies or other therapeutics. They are not vaccines. Instead, they are for people who either don't want to take vaccines, or who have taken vaccines but will not get enough protection from vaccines alone.

YESNO

Do you have any of the following immune-related/autoimmune conditions?* This field is required.

Fibromyalgia

Multiple Sclerosis

Systemic Lupus Erythematosus

Rheumatoid Arthritis

Psoriatic Arthritis

Sjorgen's Syndrome

Chronic Fatigue Syndrome

Osteoarthritis (Not a true immunological condition)

(None of the above)

Do you have pain in any of these areas of your body, from injury, muscle pain, obesity, or wear and tear ("osteoarthritis")?* This field is required.

Knee Pain/Knee Osteoarthritis

Back Pain (Muscular or Skeletal)

Hip Pain

Shoulder Pain

Hand Pain

None of the above

Other

Do you have Gout?* This field is required.

I don't have gout yet, but I do have high uric acid levels

I've started to have acute gout.

I sometimes have gout attacks.

I have chronic gout with frequent episodes of gout pain.

(I don't have gout or high uric acid)

Do you have any of the following mental health statuses:Studies for these conditions would be conducted under the supervision of a board-certified psychiatrist.

Depression (formally known as Major Depressive Disorder)

Sexual side effects from depression/antidepressants

Anhedonia/loss of pleasure/joy

Bipolar

ADD/ADHD

Schizophrenia

Anxiety (formally known as Generalized Anxiety Disorder)

Obsessive Compulsive Disorder (OCD)

Anorexia/Bulimia

Post-Traumatic Stress Disorder (PTSD)

(None of the above)

Are you currently taking any psychiatric medications? If so, could you please list?* This field is required.(Please type none if none)

Have you ever had triple-negative breast cancer?I know that is a very specific kind of cancer, but we may get a study to prevent its recurrence or to treat it soon.

YESNO

Do you currently have any kinds of cancer?Please leave blank if none

Have you had any kinds of cancer in the past?Please leave blank if none

Do you have the rare disease, Warm Autoimmune Hemolytic Anemia? (wAIHA)This is a rare disease that approximately 1 in 8000 Americans has. You'd probably know if you have it-it is where the immune system attacks its own red blood cells. We have a study upcoming for this condition.

(No or not that I know of)

Yes, a doctor has diagnosed me with wAIHA

I have Cold Autoimmune Hemolytic Anemia, not Warm.

I'm not sure.

Other

Miscellaneous/Catch AllIf we couldn't find another category for any conditions, we put them in here:

Chronic kidney disease

Kidney Stones

I'm interested in Quitting Smoking (Smoking Cessation) 🚭

I'm interested in recovery from alcoholism

I'm interested in recovery from drug addiction

Bunions on feet

Osteoporosis/Osteopenia/Bone Health

Are there any conditions that we haven't mentioned that you have and would like to participate in research on? (Optional)Feel free to leave blank if none.

Can you please complete this captcha so we know you're not a bot?* This field is required.

Do you have any questions or comments for now?(Optional)

How did you feel about this survey overall?