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MEDICAL HISTORY FORM©

Please take a moment to fill out the form below.

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

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This form is kept confidential, any information given will not be shared.

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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