Health Form Elite Clinical Studies is a multi-specialty dedicated clinical research facility in Phoenix, Arizona. Verified from Photo ID: Sex: MaleFemale Subject’s Date of Birth : Years Referral Source: Walk inInternetDatabaseAd Other Ethnicity: Hispanic or LatinoNot Hispanic or Latino Race(Check all that apply): American Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderBlack or African AmericanAsianWhite Other Is the subject able to understand, read and write English?: YesNo Has anyone told you that you are a difficult blood draw? NoYes:evaluate Your email List any Surgical Procedures:(Past or Future) Date: Date: Date: Date: Date: Date: 1.Respiratory NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 2.Cardiovascular NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 3.Head, Eyes, Ears, Nose or Throat NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 4.Musculoskeletal NoYes: If Yes, List Diagnosis and area; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 5.Gastrointestinal NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 6.Endocrine / Metabolic NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 7.Skin NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 8.Genitourinary NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 9.Neurological NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 10.Psychological/Psychiatric NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 11.Cancer NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 12.Hematological, Lymphatic, Immune NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 13.Hepatic NoYes: If Yes, List Diagnosis; Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End Diagnosis Ongoing Or End 14.Have you had a vaccine shot? NoYes Date: What Kind? 15.Do you have any difficulty swallowing a capsule or tablet? NoYes 16.Do you have a history of Drug or Alcohol Abuse in the last 5 years? NoYes If Yes, Explain: Diagnosis date: 17.Tobacco: Smoking Classification: No (Never)Yes: Ex-Smoker (Started: Stopped: ) Smoker (Started: ) [Number of pack years = (number of cigarettes per day / 20) x number of years smoked] Cigarettes: Number per day for how many years eCigarettes: Number per day for how many years Cigars: Number per day for how many years Cigarillos: Number per day for how many years Pipe: Times per day for how many years Tobacco: Grams per day for how many years Chew Tobacco: Grams per day for how many years Vape: Grams per day for how many years Pack Years: 1 Café Crème = 1.5 cigarettes a day 1 Hamlet (or similar) = 2.5 cigarettes a day 1 Havana = 4 cigarettes a day 4 Hamlet cigars a day = 10 cigarettes a day. 25 grams (1 ounce) = 50 cigarettes 50 grams tobacco (2 oz) = 100 cigarettes 18.Do you drink Alcohol or Caffeine? Alcohol (Check only one) Non-Drinker (less than 3 drinks per year) Drinker Light (less than 2 drinks per day) Light (2-4 drinks per day) Heavy (more than 4 drinks per day) Ex-Drinker Light (less than 2 drinks per day) Light (2-4 drinks per day) Heavy (more than 4 drinks per day) Caffeine (Check only one) Non-Drinker (less than 3 drinks per year) Drinker Light (less than 2 drinks per day) Light (2-4 drinks per day) Heavy (more than 4 drinks per day) Ex-Drinker Light (less than 2 drinks per day) Light (2-4 drinks per day) Heavy (more than 4 drinks per day) 19.*Females: NA: Male What form of Birth Control do you use? Start Date: Are you Menopausal? NoYes Start date: Surgically Sterile? NoYes: Operation? Date Medical Release Authorization Yes: I, (print) hereby authorize Elite Clinical Studies, LLC to contact my health care provider and or hospital to obtain my medical records per ECS’s S.O.P. #25. Name: Address: Date of Birth: Physician Name: for hospital records fill out additional HIPAA form Telephone: Fax: Address: Medical Records: General Records to include:Needed No: Elite Clinical Studies does not have my permission to obtain previous medical records. NA: I do not have a Primary Care Physician NA: Initialed to keep on file to send info at a later time: Initials:Date: Subject’s Signature: **Date: DISCLAIMER: The information contained in this facsimile message is intended for the sole confidential use of the designated recipients and may contain confidential information. If you have received this information in error, any review, dissemination, distribution or copying of this information is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us by mail or if electronic, reroute back to the sender. Submit
