Participant Information Form – Clinical Research of Central Florida

Name*
First Last
Daytime Phone*
Evening Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Medical Information (Please select all that apply)
Endocrine
- Diabetes
- Diabetic Neuropathy
- Nephropathy
- Retinopathy
Gastroenterology
- GERD
- Irritable Bowl Syndrome
- Diarrhea
- Constipation
Cardiovascular/Cerebrovascular
- High Blood Pressure
- Bad Cholesterol
- Arthritis
- Osteoarthritis
- Acute Coronary Syndrome
- Acute Thrombotic/Emobil Stroke
- Acute Stoke
- Arthritis
- Atrial Fibrillation
- Asthma
- Cerebrovascular Accidents
- Congestive Heart Failure
- DVT - with our without Pulmonary Embolism
- Dyslipidomia/Hyperlipidemia
- Hypertension
- Hyponatremia
- Myocardial Infarction
- Obesity
- Occluded Central Venous Catheter
- Prevention of Stroke on Patient with Atrial Febrillation
- Unstable Angina
Infectious Deseases
- Bacteremia
- Comnumity Acquired Pneumonia (Inpatient & OUtpatient)
- Complicated Skin and Skin Structure Infection (cSSSI)
- Complicated Urinary Tract Infection
- Hepatitis C
- Hepatitis B
- Hospital Acquired Pnuemonia
- Sepsis Syndrome
- Uncomplicated Skin Infection
Genomics
- DNA - Messenger RNA
- RNA Expression
Central Nervous System
- Alzheimer's (Adult & Geriatric)
- Attention-Deficit Hyperactivity Discorder (Pediatric and Adult)
- Bipolar I
- Bipolar II
- Carpal Tunnel Syndrome
- Dysthymic Disorder
- Generalized Anxiety Disorder (Adult & Pediatric)
- Insomnia (Adult & Pediatric)
- Major Depression Disorder (Adult & Pediatric)
- Manic Depression (Bi-polar Disorder)
- Migraine
- Mild Cognitive Impairment (Adult & Pediatric)
- Pain
- Panic Disorder
- Pathological Gambling
- Post Traumatic Stress Disorder
- Schizo-Affective Disorder
- Schizophrenia
- Social Phoebia
Other
- Medical Study Consulting Services
- Medical Study Enrollment Services
- CNS Study Consulting Services
- CNS Study Enrollment Services
- Other
Please specify other
Information
- I would like to receive a call from CRCF to discuss a project
- I would like to receive information from CRCF about events, news, and publications. (Please include your email address above)
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