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Name
Please enter your full name, as it appears on your foreign registration card.
Last Name
*
First Name
*
Middle Name
E-mail
*
Mobile phone number
*
Your ethnicity
*
Caucasian
Hispanic
Other/Mixed
Application is limited to Caucasian or Hispanic for this trial.
Nationality
*
Status of Residence
*
Permanent Visa
Student Visa
Spouse Visa
Working Visa
Working Holiday Visa
Other
Age
*
Date of Birth
*
Please enter the date in the format yyyy/mm/dd.
Height
*
cm
Weight
*
kg
BMI
*
Auto Calculated
Gender
*
Male
Female
Address
Referral
Please enter Ref. No or name and email address of a person who introduced you to the information.
Ref. No or Name
E-mail
1. Current Health Condition
(1). Are there any medications or vitamins that you use regularly?
*
No
Yes
Symptom
Medication
Date that you last used the medication
Please enter the date in the format yyyy/mm/dd.
liquid
topical
patch
Inhalant
nasal spray
eye drops
supplement
vitamin
health drink
During the trial, is it possible for you to stop taking the medication?
Yes
No
(2). Are there any medications that you often use to treat a particular symptom?
*
No
Yes
Symptom
Medication
liquid
patch
inhalant
nasal spray
eye drops
supplement
vitamin
health drink
During the trial, is it possible for you to stop taking the medication?
Yes
No
(3). Do you have physical impairments or disabilities such as those related to vision (color blindness, weak eyesight), hearing, speech, hands & feet, or spine?
*
No
Yes
Please describe the impairment or disability
(4). In the past six months, have you had any of the following symptoms (related to digestive organ disorders):
- malabsorption
- gastric regurgitation (reflux)
- peptic tumor
- erosive esophagitis
*
No
Yes
Additional information
2. Medical History (Past Injuries and Illnesses)
(1). Have you ever had any of the illnesses or chronic conditions listed below?
*
No
Yes
Epilepsy
Mental Illness
Kawasaki Disease
High Blood Pressure
Gastric Ulcer
Duodenal Ulcer
Chronic Stomach Disease
Liver Disease
Heart Disease
Kidney Disease
Diabetes
Hemorrhoids
Chronic Bronchitis
Head Injury
Verceral Injury
Rheumatism
Lung Disease
Urinary Problems
Hernia (Inguinal)
Hernia (Lumbar Disc)
Hernia (Cervical Disc)
Tuberculosis
Anemia
Bone Fracture
External Injury
Burn
Appendicitis
Peritonitis
Tonsillitis
Other
For each item above that was checked, please explain in more detail, and give your age and the treatment you received.
For example, Age 22. Fractured Right Arm
Age 20 Received Surgery
Illness/Injury and Age
Surgery
Hospitalization
IV Drip
Medication (pill)
Medication (capsule)
Medication (liquid)
Healed Naturally Over Time
Other
Please specify
Illness/Injury and Age
Surgery
Hospitalization
IV Drip
Medication (pill)
Medication (capsule)
Medication (liquid)
Healed Naturally Over Time
Other
Please specify
Illness/Injury and Age
Surgery
Hospitalization
IV Drip
Medication (pill)
Medication (capsule)
Medication (liquid)
Healed Naturally Over Time
Other
Please specify
(2). Have you ever received a blood transfusion?
*
No
Yes
What type of treatment was the blood transfusion for?
3. Allergies
(1). Have you ever had an adverse reaction to medication?
*
No
Yes
Age when reaction first occurred
Name of Medication
Symptom
Treatment
(2). Have you ever had an allergic reaction to mites, ticks, animals, or house dust?
*
No
Yes
Cause
Symptom
Did you use medication?
No
Yes
Name of Medication
Date that you last used the medication
Please enter the date in the format yyyy/mm/dd.
(3). Have you ever had atopic dermatitis?
*
No
Yes
Age when first outbreak occurred
Age when first outbreak subsided
Do you currently have any symptoms?
No
Yes
Please describe symptom
Do you use medication?
No
Yes
Name of medication
Date that you last used the medication
Please enter the date in the format yyyy/mm/dd.
(4). Have you ever had hay fever?
*
No
Yes
Age when first outbreak occurred
Age when first outbreak subsided
Do you currently have any symptoms?
No
Yes
Please describe symptom
Do you use medication?
No
Yes
Name of medication
Date that you last used the medication
Please enter the date in the format yyyy/mm/dd.
(5). Have you ever had allergic rhinitis (nasal allergies)?
*
No
Yes
Age when first outbreak occurred
Age when first outbreak subsided
Do you currently have any symptoms?
No
Yes
Please describe symptom
Do you use medication?
No
Yes
Name of medication
Date that you last used the medication
Please enter the date in the format yyyy/mm/dd.
(6). Have you ever had asthma, including childhood asthma?
*
No
Yes
Age when first outbreak occurred
Age when first outbreak subsided
Do you currently have any symptoms?
No
Yes
Please describe symptom
Do you use medication?
No
Yes
Name of medication
Date that you last used the medication
Please enter the date in the format yyyy/mm/dd.
4. Others
(1). What is the ethnicity of your parents?
*
Caucasian
Hispanic
Other/Mixed
Please specify
(2). What is the ethnicity of your grandparents?
*
Caucasian
Hispanic
Other/Mixed
Please specify
(3). Are there any foods that you can't eat, or refuse to eat?
*
No
Yes
Please specify
(4). Have you ever participated in a clinical trial before?
*
No
Yes
Name of CRU and last participated date.
(5). Starting 28 days prior to the start date of the clinic stay, can you refrain from smoking until the end of the trial?
*
Yes
No
Additional information
(6). Have you ever taken a vaccination of Hepatitis B before?
*
Yes
No