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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)
2. Contact Information
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid email address.
Do we have permission to reach you by text?
Sex (Male/Female)
3. How would you prefer to be contacted? 
5. Please tell us how you heard about CCR! Check all that apply.
7. Have you ever been diagnosed with cancer, including skin cancer or pre-cancer? 
8. Cardiology- Have you ever been diagnosed with any of the following: Check all that apply.
Space Cell Cardiology
Anemia
Atrial Fibrillation
Bleeding Disorders, other
Blood clots
Congestive Heart Failure
Coronary Artery Disease
Heart Attack
Heart Disease, other
High Blood Pressure
High Cholesterol
Pace Maker
Peripheral Vascular Disease
9. Skin- Have you ever been diagnosed with any of the following: Check all that apply.
Space Cell Skin
Acne
Actinic Keratosis (sun damage)
Alopecia Areata (patchy hair loss)
Atopic Dermatitis
Body Acne
Common Skin Warts
Hair Loss
Hyperhidrosis (excessive sweating)
Psoriasis
Rosacea
Scalp Psoriasis
Scars
Seborrheic Keratosis
10. General- Have you ever been diagnosed with any of the following: Check all that apply
Space Cell General
Chronic Fatigue
Diabetes
Gout
Lupus
Obesity
Thyroid Conditions
11. Stomach- Have you ever been diagnosed with any of the following: Check all that apply
Space Cell General
Acid Reflux
Constipation
Diarrhea
Irritable Bowl Syndrome
Stomach Ulcers
12. Urology- Have you ever been diagnosed with any of the following: Check all that apply. 
Space Cell Urology
Endometriosis
Erectile Dysfuntion
Fibroid Tumors
Interstitial Cystitis
Kidney Disease
Low Sex Drive (Men & Women)
Low Testosterone (Men)
Nocturia
Overactive Bladder
Peyronie's Disease
Benign Prostatic Hyperplasia (BPH) enlarged prostate
13. Infectious Disease- Check all that apply. Have you ever been diagnosed with any of the following:
Space Cell Infectious Disease
AIDS/HIV
Hepatitis C
Hepatitis B
Sexually Transmitted Disease
14. Orthopedic - Have you ever been diagnosed with any of the following:  Check all that apply.
Space Cell Orthopedic
Back Pain, Low
Chronic Pain
Hip Pain
Osteoarthritis (OA)
Rheumatoid Arthritis (RA)
15. Neurology- Have you ever been diagnosed with any of the following: Check all that apply.
Space Cell Neurology
Headaches
Insomnia
Migraines
Multiple Sclerosis
Mini Stroke/TIA
Neuropathy (Nerve Damage) or other Peripheral Neruopathy (Nerve Damage to Hands/Arms/Feet/Legs
Restless Leg Syndrome
Seizures
Stroke
Sciatica
Fibromyalgia
16. Psychology- Have you ever been diagnosed with any of the following: Check all that apply.
Space Cell Psychology
ADHD
Anxiety
Bipolar Disorder
Depression
Panic Disorder
Schizophrenia
17. Respiratory- Check all that apply. Have you ever been diagnosed with any of the following:
Space Cell Respiratory
Asthma
COPD
Chronic Bronchitis
Cystic Fibrosis
19. Please list all medications/supplements/vitamins you are taking (include medications only taken as needed)
 
Space Cell Medication NameDoseHow often takenReasonStart DateLast Used (If not taken regularly)
Medication #1:
Medication #2:
Medication #3:
Medication #4:
Medication #5:
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Medication #8:
Medication #9:
Medication #10:
21. 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.
By submitting my information, Coastal Clinical Research has my permission to contact me. My consent allows CCR to use text messaging and/or email as a way to contact me. Message and data rates may apply. I may contact you anytime to change these preferences or opt out.