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MEDICAL HISTORY FORM©

Please take a moment to fill out the form below.

This will help us identify trial oportunities and medical conditions that affect you.

This form is kept confidential. Any information given will not be shared or used in anyway other than for trial qualification.

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Medical History:
Smoking History (Nicotine):
Do you drink Alcohol?
Do you drink Caffeine?
Do you consume Marijuana?
Do you have any difficulty swallowing a capsule or tablet?
Do you have a history of Drug or Alcohol Abuse in the last 5 years?
Any issue with having your blood drawn?
Surgically Sterile?
HIPPA CONSENT: I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent I authorize Houston Center for Clinical Research (HCCR) to use and disclose my protected health information to carry out: • Confirmation of my diagnosis or study eligibility. • My day-to-day health monitoring. • Any other activity needed to potentialy participate in future clinical research activities. I understand that Houston Center for clinical research reserves the right to change the terms of this notice and that I may contact the site to receive the most current copy. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to that date is not affected.

Thanks for submitting!

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