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ADD YOUR INFORMATION TO OUR DATABASE
PLEASE COMPLETE THIS FORM BELOW
First name
Last name
Year of Birth
Gender
Male
Female
Other
City
Postal Code
Email
Phone
Do you have any medical conditions?
Yes
No
Do you have Diabetes Mellitus Type 2?
Yes
No
Do you have Cardiovascular Disease (CVD) - Heart or Vessels Disease?
Yes
No
Do you have Hypertension (High Blood Pressure)?
Yes
No
Did you have Cerebrovascular Accident (CVA) - Brain Stroke or Hemorrhage?
Yes
No
Do you have Migraines?
Yes
No
Do you have Gout?
Yes
No
Do you have Arthritis?
Yes
No
Do you have Fibromyalgia?
Yes
No
Do you have Chronic Pain?
Yes
No
Do you have Kidney Disease?
Yes
No
Do you have Thyroid Disease?
Yes
No
Do you have Anemia?
Yes
No
Do you have a history of alcohol abuse?
Yes
No
Do you have Obesity?
Yes
No
Do you have Male Sexual Health Problems?
Yes
No
Do you have Depression?
Yes
No
Do you have Allergies or Asthma?
Yes
No
If your medical condition is not in this list, please provide it below.
Are you currently taking any medication?
Yes
No
Do you have any history of smoking?
Yes
No
Would you like to participate as a healthy volunteer?
Yes
No
How did you hear about us?
(Please specify, i.e. Google search, Facebook ad, etc.)
Can we contact you in the future about studies that may pertain to you?
Yes
No
