You are applying for Study Number 853: UK Wide : Females Non Smokers aged 18 - 45 years of age

By completing the eligibility test below your application will be forwarded for consideration You are under no obligation to subscribe for this study unless you see the benefits of our comprehensive and professional services.

 

 
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Volunteer Registration.
Please complete the form below and submit:
Country:   Please Note
The information contained on this test is only ever used for clinical research activities. Even if you fail the test, other researches include, Mystery Shopping, Focus Research, Online Surveys, Usability Studies. Our members directory will place you in contact with Mystery Shopping groups, etc. Don't forget to read the home pages to select your level of membership should you wish to open up an abundance of opportunity and personalised unbiased direction.
First Name:
Middle:
Surname:
First Line of Address:
Second Line of Address:
City:
County/State:
Postcode/Zip:
Date of Birth:
Day
Month
Year
/   /  
Race:
Sex:
Phone No:   Please Note
So that clinics can contact you we do need at least one method of contact although both a phone number & email address will expediate contact and information delivery.
Mobile No:  
Email:  
 
1. With the exception of Asthma, have you ever suffered from any serious illness, including HIV / Severe Drug Allergies or Latex Allergies ? ( Please Specify )

 
2. With the exception of Asthma, Mild Eczema, Mild Psoriasis or Seasonal Hayfever, Do you suffer from any Medical Conditions? ( Please Specify )

 
3. With the exception of Asthma treatments, and the contraceptive pill for women, Do you take any regular prescribed medication? ( Please Specify )

 
4. How do you rate your Blood Pressure ?
 
5. Do you have?
Mild Asthma
Yes: No:
Excersise Induced Asthma?
Yes: No:
Chronic Asthma?
Yes: No:
Mild Eczema?
Yes: No:
Mild Psoriasis?
Yes: No:
Seasonal Hayfever?
Yes: No:
COPD ( Bronchitis/Emphysema)
Yes: No:
 
6. Do you have or have you ever had?
Cancer?
Yes: No:
All or part of your lung removed?
Yes: No:
Ever had a transplant IE Heart, Liver , Kidney Etc?
Yes: No:
Severe/Unstable/Uncontrolled Diabetes
( If you have normal diabetes leave this ticked NO )
Yes: No:
HIV
Yes: No:
Severe Drug Allergies
Yes: No:
Latex Allergies
Yes: No:
 
7. Do you use ?
Beta Blockers?
Yes: No:
Warfarin?
Yes: No:
Digoxin ?
Yes: No:
Cyclosporin ?
Yes: No:
Asofiaprin ?
Yes: No:
 
8.How long have you suffered from asthma?
  
9. Please check your BMI value using the calculator supplied.    
  Height Ft   In  Weight St Lb 
  
10. Smoking Status. * There are few studies for SMOKING asthmatic volunteers although they do exist. It could take some time to find a smoking study. COPD / Bronchitis or Emphysema sufferers who smoke will have greater success with finding smoking studies .
  
11. Smoking Status Time. * If you have selected you are a non smoker please indicate how long ago you stopped in days .
  
12. Do you drink Alcohol? (If so, please specify how many units per week) *A Unit is half a pint, or a glass of wine. 1 Standard pub measure of spirits Bottles (Budwieser/Breezers etc) count as 1 and 1/2 units. Volunteers with a history of alcholol abuse will not be acceptable.

Yes: No:
  Please Note
For females it is better to be under 21 units a week & for males it is better to be under 28 units a week
13. Recreational Drug Status








 
Please Noteyou are required to abstain from recreational drugs for a minimum period of 28 days prior to participation in medical trials. Clinics will perform medical checks.
 
14. Which of the following treatments do you use?
Blue Relief Inhalers: Ventolin Bricanyl  
 
Other Reflief Inhalers: Combivent Duovent  
  Atrovent      
 
Long Acting Inhalers: Serevent Oxis  
  Tiotropium      
 
Preventer Inhalers: Becotide(Brown) Pulmicort(Brown)  
  Flixotide(orange) Seretide(Purple)  
  Symbicort(red)      
           
Do you use any other Inhalers/Tablets:  
 
15. Females Only - What form of contraception do you use?  
 
16. (UK citizen Volunteers)Are you registered with a GP in this country? You will need 3 months min doctors registration .

USA Residents
Will not require any doctors registration.


Yes: No:
Please Note
If you are visiting the UK, London is the only city where you can use your overseas doctors registration details. You will require their name and fax number, and to be on the safe side, at least 6 months registration with your doctor in your home country . Your doctor will have to be wiilling to answer faxed information in english, for which Doctors are paid for their time and inconvenience.



17. When are You Available?


18. Where did you hear about this website? (Please be specific i.e. name of publication, or specific web link).

 

 
 

Please note: (By law all information will be kept strictly confidential between intended parties). Can BioTrax forward this information on to Clinics/Researchers for the intended purpose of helping you to find a suitable research activity?

Yes: No:
 

Can Biotrax and Clinics/Researchers contact you regarding research info ?

Yes: No:

 

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If you tick NO to any of the above questions we will not be able to assist you and you will NOT be registered on our database for future possibilities.

 
BioTrax takes no responsibility for any inacuracies of details supplied by vistors to this site and will not be held liable as a result. This test has been reviewed by the Data Protection Act and Hipaa as being acceptable for this purpose. Privacy Policy  Security Policy
*If you wish to opt out at any stage please email Biotrax at eligibility@biotrax.com