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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
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This question requires a valid email address.
Do we have permission to reach you by text? *This question is required.
Sex (Male/Female)
3. How do you prefer to be contacted? 
 
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? 
8. Cardiology- Have you ever been diagnosed with any of the following: 
Space Cell Check all that apply.
Anemia
Atrial Fibrillation
Blood clots
Congestive Heart Failure
Coronary Artery Disease
Heart Attack
Heart Disease, other
High Blood Pressure
High Cholesterol
Peripheral Vascular Disease
9. Infectious Disease- Have you ever been diagnosed with any of the following:
Space Cell Check all that apply
AIDS/HIV
Hepatitis B
Hepatitis C
Sexually Transmitted Disease
10. Internal Medicine- Have you ever been diagnosed with any of the following:
Space Cell Check all that apply.
Chronic Fatigue
Diabetes
Fibromyalgia
Gout
Lupus
Obesity
Thyroid Conditions
Rheumatoid Arthritis
11. Neurology- Have you ever been diagnosed with any of the following: 
Space Cell Check all that apply.
Diabetic Peripheral Neuropathy (DPN)
Headaches
Insomnia/Sleep Disorders
Migraines
Multiple Sclerosis
Restless Leg Syndrome
Seizures
Stroke
12. Orthopedics - Have you ever been diagnosed with any of the following: 
Space Cell Check all that apply
Chronic Pain
Frozen Shoulder
Low Back Pain
Osteoarthritis of the Hip
Osteoarthritis of the Knee
Osteoarthritis of the Shoulder
13. Psychology- Have you ever been diagnosed with any of the following:
Space Cell Check all that apply.
ADHD
Anxiety
Bipolar Disorder
Depression
Schizophrenia
14. Respiratory- Have you ever been diagnosed with any of the following:
Space Cell Check all that apply.
Asthma
COPD
Chronic Bronchitis
Cystic Fibrosis
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
Low Sex Drive (women)
Low Testosterone (men)
Peyronie's Disease
16. Skin- Have you ever been diagnosed with any of the following:
Space Cell Check all that apply.
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
Seborrheic Keratosis
17. Stomach- Have you ever been diagnosed with any of the following:
Space Cell Check all that apply.
Acid Reflux
Constipation
Irritable Bowl Syndrome
Stomach Ulcers
18. Urology- Have you been diagnosed with any of the following:
 
Space Cell Check all that apply
Benign Prostatic Hyperplasia (enlarged prostate)
Interstitial Cystitis (painful bladder syndrome)
Kidney Stones
Nocturia
Overactive Bladder (OAB)
19. Women's Health- Have you been diagnosed with any of the following: 
Space Cell Check all that apply:Column 2
HPV
Hot Flashes
Osteoporosis
Uterine Fibroids
Vaginal Atrophy
21. Please list all your medications/supplements (including occasional use):
 
Space Cell Medication NameDoseHow Often TakenReasonStart DateLast Used (If not taken regularly)
Medication #1:
Medication #2:
Medication #3:
Medication #4:
Medication #5:
Medication #6:
Medication #7:
Medication #8:
Medication #9:
Medication #10:
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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By voluntarily submitting my information, I represent and warrant that I agree and give permission for Alliance for Multispecialty Research, LLC. – Mobile to directly contact me using text messaging, phone calls, and email. Text message and data rates from my cell phone provider may apply. I understand that this authorization can only be revoked in writing.