{"id":380,"date":"2021-09-03T14:04:47","date_gmt":"2021-09-03T14:04:47","guid":{"rendered":"https:\/\/clinicaltrialscanada.com\/?page_id=380"},"modified":"2022-03-31T15:35:01","modified_gmt":"2022-03-31T15:35:01","slug":"add-your-information-to-our-database","status":"publish","type":"page","link":"https:\/\/clinicaltrialscanada.com\/join-a-study\/add-your-information-to-our-database\/","title":{"rendered":"Add Your Information to Our Database"},"content":{"rendered":"<div id=\"tdi_1\" class=\"tdc-zone\"><div class=\"tdc_zone tdi_2  wpb_row td-pb-row\"  >\n<style scoped>\n\/* custom css - generated by TagDiv Composer *\/\n\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.tdi_2{\r\n                    min-height: 0;\r\n                }\n<\/style><div id=\"tdi_3\" class=\"tdc-row stretch_row\"><div class=\"vc_row tdi_4  wpb_row td-pb-row tdc-element-style\" >\n<style scoped>\n\/* custom css - generated by TagDiv Composer *\/\n\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.tdi_4,\r\n                .tdi_4 .tdc-columns{\r\n                    min-height: 0;\r\n                }.tdi_4,\r\n\t\t\t\t.tdi_4 .tdc-columns{\r\n\t\t\t\t    display: block;\r\n\t\t\t\t}.tdi_4 .tdc-columns{\r\n\t\t\t\t    width: 100%;\r\n\t\t\t\t}\n\/* inline tdc_css att - generated by TagDiv Composer *\/\n\n.tdi_4{\nposition:relative;\n}\n\n.tdi_4 .td_block_wrap{ text-align:left }\n\n<\/style>\n<div class=\"tdi_3_rand_style td-element-style\" ><div class=\"td-element-style-before\"><style>\n\/* custom css - generated by TagDiv Composer *\/\n\n.tdi_3_rand_style > .td-element-style-before {\ncontent:'' !important;\nwidth:100% !important;\nheight:100% !important;\nposition:absolute !important;\ntop:0 !important;\nleft:0 !important;\ndisplay:block !important;\nz-index:0 !important;\nbackground-image:url(\"http:\/\/dev.clinicaltrialscanada.com\/wp-content\/uploads\/2021\/11\/network-g3672cba0f_1920.jpg\") !important;\nbackground-size:cover !important;\nbackground-position:center top !important;\n}\n<\/style><\/div><style>\n\/* custom css - generated by TagDiv Composer *\/\n \n.tdi_3_rand_style::after {\ncontent:'' !important;\nwidth:100% !important;\nheight:100% !important;\nposition:absolute !important;\ntop:0 !important;\nleft:0 !important;\nz-index:0 !important;\ndisplay:block !important;\nbackground: rgba(30,115,190,0.52) !important;\n}\n<\/style><\/div><div class=\"vc_column tdi_6  wpb_column vc_column_container tdc-column td-pb-span12\">\n<style scoped>\n\/* custom css - generated by TagDiv Composer *\/\n\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.tdi_6{\r\n                    vertical-align: baseline;\r\n                }.tdi_6 > .wpb_wrapper,\r\n\t\t\t\t.tdi_6 > .wpb_wrapper > .tdc-elements{\r\n\t\t\t\t    display: block;\r\n\t\t\t\t}.tdi_6 > .wpb_wrapper > .tdc-elements{\r\n\t\t\t\t    width: 100%;\r\n\t\t\t\t}.tdi_6 > .wpb_wrapper > .vc_row_inner{\r\n\t\t\t\t    width: auto;\r\n\t\t\t\t}.tdi_6 > .wpb_wrapper{\r\n\t\t\t\t    width: auto;\r\n\t\t\t\t    height: auto;\r\n\t\t\t\t}\n<\/style><div class=\"wpb_wrapper\" ><div class=\"vc_row_inner tdi_8  vc_row vc_inner wpb_row td-pb-row\" >\n<style scoped>\n\/* custom css - generated by TagDiv Composer *\/\n\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.tdi_8{\r\n                    position: relative !important;\r\n                    top: 0;\r\n                    transform: none;\r\n                    -webkit-transform: none;\r\n                }.tdi_8,\r\n\t\t\t\t.tdi_8 .tdc-inner-columns{\r\n\t\t\t\t    display: block;\r\n\t\t\t\t}.tdi_8 .tdc-inner-columns{\r\n\t\t\t\t    width: 100%;\r\n\t\t\t\t}\n<\/style><div class=\"vc_column_inner tdi_10  wpb_column vc_column_container tdc-inner-column td-pb-span12\">\n<style scoped>\n\/* custom css - generated by TagDiv Composer *\/\n\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.tdi_10{\r\n                    vertical-align: baseline;\r\n                }.tdi_10 .vc_column-inner > .wpb_wrapper,\r\n\t\t\t\t.tdi_10 .vc_column-inner > .wpb_wrapper .tdc-elements{\r\n\t\t\t\t    display: block;\r\n\t\t\t\t}.tdi_10 .vc_column-inner > .wpb_wrapper .tdc-elements{\r\n\t\t\t\t    width: 100%;\r\n\t\t\t\t}\n<\/style><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\" ><div class=\"tdm_block td_block_wrap tdm_block_column_title tdi_11 tdm-content-horiz-center td-pb-border-top td_block_template_1\"  data-td-block-uid=\"tdi_11\" >\n<style>\n\n\/* inline tdc_css att - generated by TagDiv Composer *\/\n\n.tdi_11{\npadding-top:100px !important;\npadding-bottom:100px !important;\n}\n\n<\/style>\n<style>\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.tdm_block_column_title{\r\n                  margin-bottom: 0;\r\n                  display: inline-block;\r\n                  width: 100%;\r\n                }\n<\/style><div class=\"td-block-row\"><div class=\"td-block-span12 tdm-col\">\n<style>\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\nbody .tdi_12 .tdm-title{\r\n\t\t\t\t\tcolor: #ffffff;\r\n\t\t\t\t}.tdi_12 .tdm-title{\r\n\t\t\t\t\tfont-size:55px !important;line-height:66px !important;font-weight:600 !important;\r\n\t\t\t\t}\n\n\/* phone *\/\n@media (max-width: 767px){\n\/* custom css - generated by TagDiv Composer *\/\n.tdi_12 .tdm-title{\r\n\t\t\t\t\tfont-size:32px !important;line-height:42px !important;\r\n\t\t\t\t}\n}\n<\/style><div class=\"tds-title tds-title1 td-fix-index tdi_12 \"><h3 class=\"tdm-title tdm-title-md\">ADD YOUR INFORMATION TO OUR DATABASE<\/h3><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"tdi_13\" class=\"tdc-row\"><div class=\"vc_row tdi_14  wpb_row td-pb-row\" >\n<style scoped>\n\/* custom css - generated by TagDiv Composer *\/\n\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.tdi_14,\r\n                .tdi_14 .tdc-columns{\r\n                    min-height: 0;\r\n                }.tdi_14,\r\n\t\t\t\t.tdi_14 .tdc-columns{\r\n\t\t\t\t    display: block;\r\n\t\t\t\t}.tdi_14 .tdc-columns{\r\n\t\t\t\t    width: 100%;\r\n\t\t\t\t}\n<\/style><div class=\"vc_column tdi_16  wpb_column vc_column_container tdc-column td-pb-span12\">\n<style scoped>\n\/* custom css - generated by TagDiv Composer *\/\n\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.tdi_16{\r\n                    vertical-align: baseline;\r\n                }.tdi_16 > .wpb_wrapper,\r\n\t\t\t\t.tdi_16 > .wpb_wrapper > .tdc-elements{\r\n\t\t\t\t    display: block;\r\n\t\t\t\t}.tdi_16 > .wpb_wrapper > .tdc-elements{\r\n\t\t\t\t    width: 100%;\r\n\t\t\t\t}.tdi_16 > .wpb_wrapper > .vc_row_inner{\r\n\t\t\t\t    width: auto;\r\n\t\t\t\t}.tdi_16 > .wpb_wrapper{\r\n\t\t\t\t    width: auto;\r\n\t\t\t\t    height: auto;\r\n\t\t\t\t}\n<\/style><div class=\"wpb_wrapper\" ><div class=\"wpb_wrapper td_block_empty_space td_block_wrap vc_empty_space tdi_18 \"  style=\"height: 50px\"><\/div><div class=\"td_block_wrap td_block_text_with_title tdi_19 tagdiv-type td-pb-border-top td_block_template_1\"  data-td-block-uid=\"tdi_19\" >\n<style>\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - generated by TagDiv Composer *\/\n.td_block_text_with_title{\r\n                  margin-bottom: 44px;\r\n                  -webkit-transform: translateZ(0);\r\n                  transform: translateZ(0);\r\n                }.td_block_text_with_title p:last-child{\r\n                  margin-bottom: 0;\r\n                }\n<\/style><div class=\"td-block-title-wrap\"><\/div><div class=\"td_mod_wrap td-fix-index\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f386-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/380#wpcf7-f386-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"386\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f386-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"ayitod-form-wrapper\">\n\t<div class=\"ayitod-form-heading\">\n\t\t<h3>PLEASE COMPLETE THIS FORM BELOW\n\t\t<\/h3>\n\t<\/div>\n\t<div class=\"ayitod-form-flex\">\n\t\t<div class=\"ayitod-form-left\">\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">First name<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-first-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stady-first-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Last name<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-last-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stady-last-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Year of Birth<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required ctc-cf7-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"mm-dd-yyyy\" value=\"\" type=\"text\" name=\"stady-date\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Gender<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-gender\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"stady-gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-gender\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">City<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stady-city\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Postal Code<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-postal-code\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stady-postal-code\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Email<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"stady-email\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Phone<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"stady-phone\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have any medical conditions?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-any-medical-conditions\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-any-medical-conditions\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-any-medical-conditions\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Diabetes Mellitus Type 2?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-diabetes-mellitus-type-2\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-diabetes-mellitus-type-2\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-diabetes-mellitus-type-2\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Cardiovascular Disease (CVD) - Heart or Vessels Disease?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-cardiovascular-disease\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-cardiovascular-disease\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-cardiovascular-disease\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Hypertension (High Blood Pressure)?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-hypertension\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"stady-hypertension\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"stady-hypertension\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Did you have Cerebrovascular Accident (CVA) - Brain Stroke or Hemorrhage?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-cerebrovascular-accident\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-cerebrovascular-accident\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-cerebrovascular-accident\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Migraines?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-migraines\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-migraines\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-migraines\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Gout?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-gout\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-gout\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-gout\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Arthritis? <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-arthritis\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-arthritis\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-arthritis\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Fibromyalgia?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-fibromyalgiar\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-fibromyalgiar\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-fibromyalgiar\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"ayitod-form-right\">\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Chronic Pain? <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-chronic-pain\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-chronic-pain\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-chronic-pain\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Kidney Disease?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-kidney-disease\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-kidney-disease\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-kidney-disease\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Thyroid Disease?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-thyroid-disease\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-thyroid-disease\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-thyroid-disease\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Anemia?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-anemia\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-anemia\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-anemia\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have a history of alcohol abuse? <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-history-of-alcohol-abuse\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-history-of-alcohol-abuse\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-history-of-alcohol-abuse\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Obesity?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-obesity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-obesity\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-obesity\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Male Sexual Health Problems?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-male-sexual-health-problems\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-male-sexual-health-problems\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-male-sexual-health-problems\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Depression?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-depression\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-depression\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-depression\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have Allergies or Asthma?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-allergies-or-asthma\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-allergies-or-asthma\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-allergies-or-asthma\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">If your medical condition is not in this list, please provide it below.<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-medical-condition-list\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"stady-medical-condition-list\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Are you currently taking any medication?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-currently-taking-any-medication\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-currently-taking-any-medication\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-currently-taking-any-medication\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Do you have any history of smoking?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-any-history-of-smoking\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-any-history-of-smoking\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-any-history-of-smoking\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Would you like to participate as a healthy volunteer?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-participate-as-a-healthy-volunteer\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-participate-as-a-healthy-volunteer\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-participate-as-a-healthy-volunteer\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">How did you hear about us?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-hear-about-us\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stady-hear-about-us\" \/><\/span><br \/>\n<span class=\"ayitod-form-field-subtext\">(Please specify, i.e. Google search, Facebook ad, etc.)<\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ayitod-form-field\">\n\t\t\t\t<p><span class=\"ayitod-form-field-text\">Can we contact you in the future about studies that may pertain to you?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stady-can-we-contact-you\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stady-can-we-contact-you\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stady-can-we-contact-you\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"ayitod-form-submit\">\n\t\t<div class=\"input-wrapper\">\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/><i class=\"form-custom-icon tdc-font-fa tdc-font-fa-angle-right\"><\/i>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\n\t<\/div>\n<\/div><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<\/div><\/div><\/div><\/div><\/div><\/div><div id=\"tdi_20\" class=\"tdc-row\"><div class=\"vc_row tdi_21  wpb_row td-pb-row\" >\n<style scoped>\n\/* custom css - generated by TagDiv Composer *\/\n\n\/* custom css - generated by TagDiv Composer *\/\n\/* custom css - 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32px\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":1150,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/pages\/380"}],"collection":[{"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/comments?post=380"}],"version-history":[{"count":24,"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/pages\/380\/revisions"}],"predecessor-version":[{"id":1880,"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/pages\/380\/revisions\/1880"}],"up":[{"embeddable":true,"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/pages\/1150"}],"wp:attachment":[{"href":"https:\/\/clinicaltrialscanada.com\/wp-json\/wp\/v2\/media?parent=380"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}