Segal Trials Register Now
REGISTER NOW
Questionnaire
Your Information
QUESTIONNAIRE
If you would like to be contacted about participating in a clinical trial, please complete the following form.
1. Gender *
Male   Female  
2. Date of Birth *
Month
Day ex. 08
Year ex. 1954
3. City / State location where you live *
Enter 5-digit zip code
4. If female, are you capable of becoming pregnant?
Yes   No  
If yes, what type of birth control do you use?
(i.e. None, abstinence, birth control pills, condom, etc.)
5. Are you pregnant or nursing?
Yes   No  
6. Have you been hospitalized in the past 5 years?
Yes   No  
If yes, for what?
7. Do you have or have you had any of the following? (Check all that apply)
Seizures
Head trauma or injury
Stroke
Heart attack
Heart disease
Lung disease
Kidney disease
Liver disease
HIV +
Hepatitis
Diabetes
Colitis
Chron’s disease
Autoimmune disease
Do not know
Other:
8. What indications are you interested in? (Check all that apply)
Adolescent Depression
Adolescent Bipolar Depression
Athlete’s Foot
Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD)
Alzheimer’s Disease
Anxiety
Arthritis
Asthma
Bipolar Depression
Bipolar Disorder
Decrease in Sex Drive
Depression
Diabetes
Eating Disorder
Endometriosis or Pelvic Pain
Erectile Dysfunction
Genital Warts
Headaches
Heavy Menstrual Bleeding
High Blood Pressure (Hypertension)
Hot Flashes associated with Menopause
Insomnia
Memory Loss
Oral Contraception
Osteoarthritis
Osteoporosis
Overactive Bladder
Pain
Premature Ejaculation
Premenstrual Syndrome
Psychotic Depression
Sexually Transmitted Diseases
Schizoaffective Disorder
Schizophrenia
Substance Abuse
Alcohol
Cocaine
Heroin
Methamphetamine
Pain Killers
Uterine Fibroids
Yeast Infection
Other:
9. How did you hear about us? *
Other:
* Indicates required question.