Participant Health Questionnaire
Thank you for your interest in participating in our clinical research study. Please complete this survey to help us determine your eligibility. Your responses will be reviewed, and if you qualify, we will contact you to schedule a screening visit. This survey should take about 10-15 minutes to complete.
Personal Information:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
City
*
State
*
Healthcare Visits
Primary Care:
Have you visited your primary care doctor in the past year?
*
Yes
No
If yes, please provide the date(s) of your visit(s):
How frequently do you see your primary care doctor?
Once a month
Every 3-6 months
Once a year
Other
Specialty Doctor:
Have you visited any specialist doctors in the past year?
*
Yes
No
If yes, please provide the date(s) of your visit(s):
How frequently do you see your specialist doctor?
Once a month
Every 3-6 months
Once a year
Other
Emergency Room (ER) Visits:
Have you visited the ER in the past year?
*
Yes
No
If yes, please provide the date(s) of your visit(s):
Hospitalization:
Have you been hospitalized in the past year?
*
Yes
No
If yes, please provide the date(s) and reason(s) for your hospitalization:
Medical Conditions and Medications:
Medical History:
Do you have any of the following medical conditions? (Check all that apply)
*
Diabetes
High Blood Pressure (Hypertension)
Heart Disease
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Kidney Disease
Liver Disease
Cancer
None
Other
Are you taking medication for diabetes?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for diabetes changed?
Frequently
Occasionally
Rarely
Are you taking medication for high blood pressure?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for high blood pressure changed?
Frequently
Occasionally
Rarely
Are you taking medication for Heart Disease?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for heart disease changed?
Frequently
Occasionally
Rarely
Are you taking medication for asthma?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for asthma changed?
Frequently
Occasionally
Rarely
Are you taking medication for COPD?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for COPD changed?
Frequently
Occasionally
Rarely
Are you taking medication for kidney disease?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for kidney disease changed?
Frequently
Occasionally
Rarely
Are you taking medication for liver disease?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for liver disease changed?
Frequently
Occasionally
Rarely
Are you taking medication for cancer?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for cancer changed?
Frequently
Occasionally
Rarely
Are you taking medication for this condition?
*
Yes
No
Is this a recent condition or a long-standing history?
Recent
Long-standing
How frequently has your medication for this condition changed?
Frequently
Occasionally
Rarely
Allergies
Do you have any severe allergies (e.g., to vaccines, medications)?
*
Yes
No
If yes, please specify
Medications
Are you currently taking any other medications (including corticosteroids, immunosuppressive treatments, or antiviral medications)?
*
Yes
No
If yes, please list the medications and their doses:
Vaccinations:
Have you received any vaccinations in the past 6 months? (Check all that apply)
COVID-19 Vaccine
Influenza Vaccine
RSV Vaccine
Combination Vaccine (COVID-19, Influenza)
If yes, provide the date(s) (MM-YYYY) received:
If yes, provide the date(s) (MM-YYYY) received:
If yes, provide the date(s) (MM-YYYY) received:
If yes, provide the date(s) (MM-YYYY) received:
Additional Health Information:
Infections
Have you ever tested positive for the following infections? (Check all that apply)
*
COVID-19
Influenza
RSV
If yes, provide the date of infection onset and stop date:
Did you take any medication/treatment for it?
Yes
No
If yes, what was the medication/treatment and when was your last dose?
If yes, provide the date of infection onset and stop date:
Did you take any medication/treatment for it?
Yes
No
If yes, what was the medication/treatment and when was your last dose?
If yes, provide the date of infection onset and stop date:
Did you take any medication/treatment for it?
Yes
No
If yes, what was the medication/treatment and when was your last dose?
Cardiac Conditions:
Have you ever had myocarditis, pericarditis, or myopericarditis?
*
Yes
No
If yes, when was your last episode?
Neurological Conditions:
Have you ever had Guillain-Barre syndrome?
*
Yes
No
If yes, please provide details:
Cancer:
Have you had cancer in the past 5 years?
*
Yes
No
If yes, what type of cancer and when was it diagnosed/treated?
Immune System:
Do you have any conditions that affect your immune system (e.g.,HIV, asplenia, Hepatitis B, Hepatitis C)?
*
Yes
No
If yes, please provide details:
New symptoms/upcoming diagnostic tests
Are you experiencing any new symptoms for which you are planning to see a doctor or are currently seeing a doctor for?
*
Yes
No
If yes, please provide details:
Recent Clinical Studies:
Have you participated in any clinical studies in the past 3 months?
*
Yes
No
If yes, please provide details:
Recent Blood Donation and Transfusion:
Have you recently donated any blood products?
*
Yes
No
If yes, please provide the date:
-
Month
-
Day
Year
Date
How frequently do you donate blood?
Frequently
Occasionally
Rarely
Have you recently received blood transfusions?
*
Yes
No
If yes, please provide the date:
-
Month
-
Day
Year
Date
Submit
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