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FORMULARIO DE ADMISIÓN DE PACIENTES

Cardiovascular - Check all that apply
Immune / Allergy - Check all that apply
Neurological - Check all that apply
Dermatological - Check all that apply
Urology / Nephrology - Check all that apply
Psychiatric - Check all that apply
Endocrine - Check all that apply
Gastroenterology - Check all that apply
Musculoskeletal - Check all that apply
Respiratory - Check all that apply
Hepatic - Check all that apply
Hematological - Check all that apply
Head / Ears / Eyes / Nose / Throat - Check all that apply
Are you male or female?
Male
Female

You will be shown the next relevant question based on your answer.

Reproductive (Male) - Check all that apply
Reproductive (Female) - Check all that apply
Contraception / Child-Bearing Potential - Check all that apply
Smoking History
Never Smoked
Ex-Smoker
Current Smoker

You will be shown the next relevant question based on your answer.

Alcohol Consumption
Never
Social (<1 Per Month)
Often

You will be shown the next relevant question based on your answer.

Do you have a latex allergy?
Yes
No
Do you have any food or drug allergies?
Yes
No

Food & Drug Allergies

Ex:

Name: Tylenol

Dose: 500mg

How Often: Daily

Started: 2010

Ex:

Surgery: Tonsillectomy

Reason: Tonsillitis

Date: 1995

Please type 'N/A' if you have not participated in a clinical trial previously.

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