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https://app.surveygizmo.com/builder/build/id/2366000APPLY ONLINE to see if you qualify! FINAL Mobile Interaction OFF

Complete this form to see if you qualify for any of our currently enrolling studies.

1. What studies are you interested in? (check all that apply)

Gout (Mobile & Daphne office)
Covid 19 Vaccine
T2 Diabetes with Obesity and Cardiovascular Risk
Sexually Transmitted Disease (Self Swab)
Healthy Volunteer Vaccines
OTHER (Write In) Please enter an 'other' value for this selection.

2. Contact Information

First Name *This question is required.

Middle Initial

Last Name *This question is required.

DOB *This question is required.

Address

City

State

Zip *This question is required. This question requires a valid number format.

Email This question requires a valid email address.

Phone *This question is required.

Work Phone

Mobile Phone

Do we have permission to reach you by text? *This question is required.

Height *This question is required.

Race *This question is required.

Weight *This question is required.

Sex (Male/Female)

3. How do you prefer to be contacted?

Text
Phone Call
Email

4. What is the best time to contact you?

5. Please tell us how you heard about CCR! Check all that apply. *This question is required.

7. Have you ever been diagnosed with cancer, including skin cancer or pre-cancer?

Yes
No
Other - Write In Please enter an 'other' value for this selection.

8. Cardiology- Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply.
Anemia	Anemia: Check all that apply.
Atrial Fibrillation	Atrial Fibrillation: Check all that apply.
Blood clots	Blood clots: Check all that apply.
Congestive Heart Failure	Congestive Heart Failure: Check all that apply.
Coronary Artery Disease	Coronary Artery Disease: Check all that apply.
Heart Attack	Heart Attack: Check all that apply.
Heart Disease, other	Heart Disease, other: Check all that apply.
High Blood Pressure	High Blood Pressure: Check all that apply.
High Cholesterol	High Cholesterol: Check all that apply.
Peripheral Vascular Disease	Peripheral Vascular Disease: Check all that apply.
Enter another option	Other: Check all that apply.

9. Infectious Disease- Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply
AIDS/HIV	AIDS/HIV: Check all that apply
Hepatitis B	Hepatitis B: Check all that apply
Hepatitis C	Hepatitis C: Check all that apply
Sexually Transmitted Disease	Sexually Transmitted Disease: Check all that apply
Enter another option	Other: Check all that apply

10. Internal Medicine- Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply.
Chronic Fatigue	Chronic Fatigue: Check all that apply.
Diabetes	Diabetes: Check all that apply.
Fibromyalgia	Fibromyalgia : Check all that apply.
Gout	Gout: Check all that apply.
Lupus	Lupus: Check all that apply.
Obesity	Obesity: Check all that apply.
Thyroid Conditions	Thyroid Conditions: Check all that apply.
Rheumatoid Arthritis	Rheumatoid Arthritis: Check all that apply.
Enter another option	Other: Check all that apply.

11. Neurology- Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply.
Diabetic Peripheral Neuropathy (DPN)	Diabetic Peripheral Neuropathy (DPN): Check all that apply.
Headaches	Headaches: Check all that apply.
Insomnia	Insomnia: Check all that apply.
Hypersomnia (Excessive Daytime Sleepiness)	Hypersomnia (Excessive Daytime Sleepiness): Check all that apply.
Migraines	Migraines: Check all that apply.
Multiple Sclerosis	Multiple Sclerosis: Check all that apply.
Restless Leg Syndrome	Restless Leg Syndrome: Check all that apply.
Seizures	Seizures: Check all that apply.
Stroke	Stroke: Check all that apply.
Enter another option	Other: Check all that apply.

12. Orthopedics - Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply
Chronic Pain	Chronic Pain: Check all that apply
Frozen Shoulder	Frozen Shoulder : Check all that apply
Low Back Pain	Low Back Pain: Check all that apply
Osteoarthritis of the Hip	Osteoarthritis of the Hip: Check all that apply
Osteoarthritis of the Knee	Osteoarthritis of the Knee: Check all that apply
Osteoarthritis of the Shoulder	Osteoarthritis of the Shoulder: Check all that apply
Enter another option	Other: Check all that apply

13. Psychology- Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply.
ADHD	ADHD: Check all that apply.
Anxiety	Anxiety: Check all that apply.
Bipolar Disorder	Bipolar Disorder: Check all that apply.
Depression	Depression: Check all that apply.
Schizophrenia	Schizophrenia: Check all that apply.
Enter another option	Other: Check all that apply.
Enter another option	Other: Check all that apply.

14. Respiratory- Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply.
Asthma	Asthma: Check all that apply.
COPD	COPD: Check all that apply.
Chronic Bronchitis	Chronic Bronchitis: Check all that apply.
Cystic Fibrosis	Cystic Fibrosis: Check all that apply.
Enter another option	Other: Check all that apply.

15. Sexual Health- Have you been diagnosed or experience symptoms with any of the following:

Space Cell	Check all that apply.	Column 2
Erectile Dysfunction	Erectile Dysfunction: Check all that apply.	Erectile Dysfunction: Column 2
Low Sex Drive (women)	Low Sex Drive (women): Check all that apply.	Low Sex Drive (women): Column 2
Low Testosterone (men)	Low Testosterone (men): Check all that apply.	Low Testosterone (men): Column 2
Peyronie's Disease	Peyronie's Disease: Check all that apply.	Peyronie's Disease: Column 2
Enter another option	Other: Check all that apply.	Other: Column 2

16. Skin- Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply.
Acne	Acne: Check all that apply.
Actinic Keratosis (sun damage)	Actinic Keratosis (sun damage): Check all that apply.
Alopecia Areata (patchy hair loss)	Alopecia Areata (patchy hair loss): Check all that apply.
Atopic Dermatitis	Atopic Dermatitis: Check all that apply.
Body Acne	Body Acne: Check all that apply.
Common Skin Warts	Common Skin Warts: Check all that apply.
Hair Loss	Hair Loss: Check all that apply.
Hyperhidrosis (excessive sweating)	Hyperhidrosis (excessive sweating): Check all that apply.
Psoriasis	Psoriasis: Check all that apply.
Rosacea	Rosacea: Check all that apply.
Scalp Psoriasis	Scalp Psoriasis : Check all that apply.
Seborrheic Keratosis	Seborrheic Keratosis: Check all that apply.
Enter another option	Other: Check all that apply.

17. Stomach- Have you ever been diagnosed with any of the following:

Space Cell	Check all that apply.
Acid Reflux	Acid Reflux: Check all that apply.
Constipation	Constipation: Check all that apply.
Irritable Bowl Syndrome	Irritable Bowl Syndrome: Check all that apply.
Stomach Ulcers	Stomach Ulcers: Check all that apply.
Enter another option	Other: Check all that apply.

18. Urology- Have you been diagnosed with any of the following:

Space Cell	Check all that apply
Benign Prostatic Hyperplasia (enlarged prostate)	Benign Prostatic Hyperplasia (enlarged prostate): Check all that apply
Interstitial Cystitis (painful bladder syndrome)	Interstitial Cystitis (painful bladder syndrome): Check all that apply
Kidney Stones	Kidney Stones: Check all that apply
Nocturia	Nocturia: Check all that apply
Overactive Bladder (OAB)	Overactive Bladder (OAB): Check all that apply
Enter another option	Other: Check all that apply

19. Women's Health- Have you been diagnosed with any of the following:

Space Cell	Check all that apply:	Column 2
HPV	HPV: Check all that apply:	HPV: Column 2
Hot Flashes	Hot Flashes: Check all that apply:	Hot Flashes: Column 2
Osteoporosis	Osteoporosis: Check all that apply:	Osteoporosis: Column 2
Uterine Fibroids	Uterine Fibroids: Check all that apply:	Uterine Fibroids: Column 2
Vaginal Atrophy	Vaginal Atrophy : Check all that apply:	Vaginal Atrophy : Column 2
Enter another option	Other: Check all that apply:	Other: Column 2

20. Comments:

21. Please list all your medications/supplements (including occasional use):

Space Cell	Medication Name	Dose	How Often Taken	Reason	Start Date	Last Used (If not taken regularly)
Medication #1:	Medication #1: : Medication Name	Medication #1: : Dose	Medication #1: : How Often Taken	Medication #1: : Reason	Medication #1: : Start Date	Medication #1: : Last Used (If not taken regularly)
Medication #2:	Medication #2:: Medication Name	Medication #2:: Dose	Medication #2:: How Often Taken	Medication #2:: Reason	Medication #2:: Start Date	Medication #2:: Last Used (If not taken regularly)
Medication #3:	Medication #3:: Medication Name	Medication #3:: Dose	Medication #3:: How Often Taken	Medication #3:: Reason	Medication #3:: Start Date	Medication #3:: Last Used (If not taken regularly)
Medication #4:	Medication #4:: Medication Name	Medication #4:: Dose	Medication #4:: How Often Taken	Medication #4:: Reason	Medication #4:: Start Date	Medication #4:: Last Used (If not taken regularly)
Medication #5:	Medication #5:: Medication Name	Medication #5:: Dose	Medication #5:: How Often Taken	Medication #5:: Reason	Medication #5:: Start Date	Medication #5:: Last Used (If not taken regularly)
Medication #6:	Medication #6:: Medication Name	Medication #6:: Dose	Medication #6:: How Often Taken	Medication #6:: Reason	Medication #6:: Start Date	Medication #6:: Last Used (If not taken regularly)
Medication #7:	Medication #7:: Medication Name	Medication #7:: Dose	Medication #7:: How Often Taken	Medication #7:: Reason	Medication #7:: Start Date	Medication #7:: Last Used (If not taken regularly)
Medication #8:	Medication #8:: Medication Name	Medication #8:: Dose	Medication #8:: How Often Taken	Medication #8:: Reason	Medication #8:: Start Date	Medication #8:: Last Used (If not taken regularly)
Medication #9:	Medication #9:: Medication Name	Medication #9:: Dose	Medication #9:: How Often Taken	Medication #9:: Reason	Medication #9:: Start Date	Medication #9:: Last Used (If not taken regularly)
Medication #10:	Medication #10:: Medication Name	Medication #10:: Dose	Medication #10:: How Often Taken	Medication #10:: Reason	Medication #10:: Start Date	Medication #10:: Last Used (If not taken regularly)

22. List all surgeries you've had including dates (approximate):

23. Do we have your permission to keep your information in our database for consideration in future research studies? If no, we will destory this information. *This question is required.

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