Health Form


    1.Respiratory





    2.Cardiovascular





    3.Head, Eyes, Ears, Nose or Throat





    4.Musculoskeletal









    5.Gastrointestinal





    6.Endocrine / Metabolic




    7.Skin





    8.Genitourinary




    9.Neurological




    10.Psychological/Psychiatric





    11.Cancer





    12.Hematological, Lymphatic, Immune





    13.Hepatic





    14.Have you had a vaccine shot?


    15.Do you have any difficulty swallowing a capsule or tablet?

    16.Do you have a history of Drug or Alcohol Abuse in the last 5 years?


    17.Tobacco: Smoking Classification:





    18.Do you drink Alcohol or Caffeine?

    Alcohol (Check only one)

    (less than 3 drinks
    per year)







    Caffeine (Check only one)

    (less than 3 drinks
    per year)







    19.*Females:

    What form of Birth Control do you use?

    Are you Menopausal?





    20.*Males:

    What form of Birth Control do you use?




    The information listed on this history form will be kept for our database purposes ONLY.
    Elite Clinical Studies, LLC is a HIPAA covered entity and will keep all of your information PRIVATE.

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    ******************************************

    For my personal safety, I certify that my Medical History Information given to Elite Clinical Studies, LLC in this packet is true, accurate and complete to the best of my knowledge.




    Dr. Joseph L. Lillo, D.O., FNLA, CPI

    Certified Principal Investigator
    4520 E Indian School Road
    Phoenix, AZ 85018
    602.788.3437 phone 602.840.4868 fax










    DISCLAIMER:

    Up-Dated Medical History:










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