AZ Trials - 001 Screening Questionnaire

Thank you for your interest in learning more about our clinical research opportunities. See if you may qualify by answering a few short questions. By filling out the interest form below, you consent to being contacted by our patient enrollment specialists via phone, text, or email with more information.

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Camp ID

First Name

Last Name

Select Gender

Gender

Date of Birth

Date

Language

Current Date

Date

Age

Primary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Secondary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Email

example@example.com

Metro Area

Zip Code

Metro Code

State ID

CampRefID

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Have you ever been diagnosed with any ONE of the following conditions?(Select all that apply.)

Have you ever been diagnosed with diabetes mellitus?

Are you currently receiving treatment for diabetes mellitus (e.g., oral or injectable pharmacotherapy)?

Do you have a history of hypertension?

Do you have a history of atrial flutter and/or atrial fibrillation?

Do you have a history of heart failure?

Are you currently taking spironolactone (Aldactone) and planning to continue its use?

Eligibility Status