• 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.

     

    • Section 1: Personal Information 

    • 1.1 Full Name

    • 1.2 Date of Birth:

    • 1.2.1 Please select your date of birth?*
       - -
    • 1.2.2Today's date*
       - -

    • 1.3 Contact Details

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • 1.4 Location:

    • You will only be able to book an appointment in the following areas:

      • Houston (Cyfair, Tomball or Sugarland)
      • Dallas (Irving)
      • Seattle
      • Jersey City
      • Boston
      • Philadelphia

       

    • Section 2: Medical Conditions and Medications 

    • “Fantastic progress so far! Now, let’s dive into your medical history. Remember, every detail helps us make the world a healthier place. Keep it up!”

    • 2.0 Vaccination and Infection History

    • 2.0.1 Please select all the vaccines you have received in the last 6 months.*
    • 2.0.1.1 Please provide further details about each of the vaccines you have gotten.*
    • 2.0.2 Have you ever tested positive for Covid, Flu, RSV or Shingles?*
    • 2.0.2.1 Please provide details about the above infections you have been diagnosed with. *

    • 2.0.3 Infections:

    • 2.0.3.1 Have you had any other acute illnesses or infections (e.g., sudden flu, fever) in the past 3 months?*
    • 2.0.3.1.1 Please give some more details about the acute illness.*

    • 2.1 Medical History:

    • 2.1 Please note if you have ever or are currently experiencing any of the following"*

    • 2.1.1 Diabetes

    • 2.1.1.1 What type of Diabetes have you been diagnosed with?*
    • 2.1.1.2 Have you had this condition for longer than or less than 6 months?*
    • 2.1.1.3 Are you taking any medications for your Diabetes?*
    • 2.1.1.4 How frequently has your Diabetes medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.1.5 Please provide further details on your medication for Diabetes.*

    • 2.1.2 High Blood Pressure (Hypertension):

    • 2.1.2.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.2.2 Are you taking any medications for your High Blood Pressure?*
    • 2.1.2.3 How frequently has your High Blood Pressure medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.2.4 Please provide further details on your medication for High Blood Pressure.*

    • 2.1.3 Heart Disease:

    • 2.1.3.0 Have you ever had any medical devices placed in your body such as a pacemaker, ear/hip implant, shunt, or any others?*
    • 2.1.3.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.3.2 Are you taking any medications for your Heart Disease?*
    • 2.1.3.3 How frequently has your Heart Disease medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.3.4 Please provide further details on your medication for Heart Disease.*

    • 2.1.4 Asthma:

    • 2.1.4.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.4.2 Are you taking any medications for your Asthma?*
    • 2.1.4.3 How frequently has your Asthma medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.4.4 Please provide further details on your medication for Asthma.*

    • 2.1.5 Chronic Obstructive Pulmonary Disease (COPD):

    • 2.1.5.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.5.2 Are you taking any medications for your COPD?*
    • 2.1.5.3 How frequently has your COPD medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.5.4 Please provide further details on your medication for COPD.*
    • 2.1.5.5 Do you use extra oxygen to help with your breathing because of your lung condition?*
    • 2.1.5.6 Do you take that during the day, at night, or both?*

    • 2.1.6 Kidney Disease:

    • 2.1.6.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.6.2 "Are you currently getting any treatment for your kidneys, like dialysis?"*
    • 2.1.6.2 Are you taking any medications for your Kidney Disease?*
    • 2.1.6.3 How frequently has your Kidney Disease medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.6.4 Please provide further details on your medication for Kidney Disease.*

    • 2.1.7 Liver Disease:

    • 2.1.7.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.7.2 Are you taking any medications for your Liver Disease?*
    • 2.1.7.3 How frequently has your Liver Disease medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.7.4 Please provide further details on your medication for Liver Disease.*

    • 2.1.8 Cancer:

    • 2.1.8.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.8.2 Are you taking any medications for your Cancer?*
    • 2.1.8.3 How frequently has your Cancer medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.8.4 Please provide further details on your medication for Cancer.*

    • 2.1.9 Any other medical conditions not discussed above:

    • 2.1.9.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.9.2 Are you taking medication for this condition?*
    • 2.1.9.3 How frequently has your medication for this condition changed?*
    • 2.1.9.4 Please provide further details on your medication for this condition.*

    • 2.1.10 Mental Health:

    • 2.1.10.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.10.2 Are you taking any medications for your Mental Health?*
    • 2.1.10.3 How frequently has your Mental Health medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.10.4 Please provide further details on your medication for Mental Health.*

    • 2.1.11 Digestive System Diseases (Gastro)

    • 2.1.11.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.11.2 Are you taking any medications for your Digestive System Disease?*
    • 2.1.11.3 How frequently has your Digestive System Disease medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.11.4 Please provide further details on your medication for Digestive System Disease.*
    • 2.1.11.1 Do you have any conditions that affect your Gastrointestinal (stomach) system? Some examples might be: upset stomach, frequent heartburn/acid reflux, irritable bowel syndrome, or Crohn's disease?

    • 2.1.12 Stroke

    • 2.1.12.1 Please provide the date you experienced the stroke
       - -

    • 2.1.13 Autoimmune Diseases:

    • 2.1.13.1 Have you had this condition for longer than or less than 6 months?*
    • 2.1.13.2 Are you taking any medications for your Autoimmune Disease?*
    • 2.1.13.3 How frequently has your Autoimmune disease medication been changed? This could be a change in dosage or starting a new medication completely.*
    • 2.1.13.4 Please provide further details on your medication for Autoimmune Disease.*

    • 2.2 Allergies:

    • 2.2.1 Do you have any severe allergies? (medications, foods, or vaccines)*
    • 2.2.1.1 Please provide details.*
    • 2.2.2 Please confirm if you have allergies to vaccines specifically?*

    • 2.3 Medications:

    • 2.3.1 Are you taking any medications like steroids, inhalers, immunosuppressants, antiviral medicines, cholesterol medicine, biologics, chemotherapy, or any treatments (other than the ones you have listed above).*
    • 2.3.1.1 Please provide details.*
    • Section 3: Healthcare Visits 

    • You’re halfway there! Time to talk about your healthcare visits. This is where we get to know you even better!

    • 3.1 Primary Care Doctor:

    • 3.1.1 Have you visited your primary care physician in the past year?*
    • 3.1.1.1 Please provide the date of your most recent visit.*
       - -
    • 3.1.1.3 How often do you visit your primary doctor?*

    • 3.2 Specialist Doctor:

    • 3.2.1 Have you visited any specialist doctors for any of the conditions you have mentioned previously in the past year?*
    • 3.2.1.1 Please provide details*
    • 3.2.1.2 How frequently do you see your specialist doctor?*

    • 3.3 Emergency Room (ER) Visits:

    • 3.3.1 Have you visited the ER or been hospitalized in the past year?*
    • 3.3.1.1 Please provide the date of your visit please?*
       - -

    • 3.5 Surgical Procedures

    • 3.5.1 Have you ever had or will have a surgical procedure?*
    • 3.5.1.1 What is the date and nature of the procedure?*
    • Section 4: Additional Health Information 

    • You’re on the home stretch! Just a few more details and we’ll be all set. Your participation is invaluable, and we appreciate your dedication. Finish strong!

    • 4.1 Immune System:

    • 4.1.1 Do you have any conditions that affect your immune system such as the following:*
    • 4.1.1.2 Is your Hepatitis B or C "Treated" or "Active"?*
    • 4.1.1.4 When was the last date when you got treated for the above diseases?*
       - -
    • 4.1.1.5 Today's Date*
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    • 4.2 New symptoms/upcoming diagnostic tests

    • 4.2.1 Are you currently experiencing any new symptoms that you're planning to see a doctor for?*
    • 4.2.1.1 Are you currently undergoing any testing for these unknown or undiagnosed symptoms?*

    • 4.3 Recent Clinical Studies:

    • 4.3.1 Have you participated in any clinical research studies in the last 3 months?*
    • 4.3.1.2 Can you also mention when that trial was completed?*
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    • 4.4 Recent Blood Donation and Transfusion:

    • 4.4.1 Have you recently donated any blood or plasma in the last 28 days?*
    • 4.4.1.1 Please provide the date*
       - -
    • 4.4.1.2 How often have you donated blood or plasma?*
    • 4.4.2 Have you recently received any blood transfusions?*
    • 4.4.2.1 When did you receive that blood transfusion?*
       - -

    • Book an Appointment:

    • Tomball Site Address: 13406 Medical Complex Dr.Ste 190, Tomball, TX 77375*
    • Cyfair Site Address: 11830 FM 1960 West, Houston*
    • Dallas Site Address: 2021 N McArthur Blvd, Irving, TX, 75061*
    • Martin Site Address: 710 Lawrence St.Tomball, TX 77375*
    • Sugarland Site Address: 1111 Highway 6, Ste 250 Sugar Land, TX 77478*
    • Seattle Site Address: 600 Broadway, Suite 340, Seattle, WA 98122*
    • Philadelphia Site Address: 231 N Broad St., 3rd Floor Philadelphia, PA 19107*
    • Jersey City Site Address: 1 Journal Square Plaza, Jersey City, NJ 07306*
    • Boston Site Address: 209 Harvard St, Brookline, MA 02446*
    • Should be Empty: