Application Form

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Title:

First name:
Last name:

Address:

City:

State:

Zip code:

Your Email

How did you hear about ICON?

If Other please specify

Gender

Ethnic Origin:

If Other please specify

Date Of Birth

Age

Height/Weight

[group metres / kgs]

Height

Weight

[/group]

[group feet / lbs]

Height

Weight

[/group]

Are you currently taking any medication?
YesNo

If yes please list names

Please check any of the following conditions that apply to you:

High blood pressure

high blood

[group high blood]

Details, e.g. Dates, treatments, symptoms

[/group]

Low blood pressure

low blood

[group low blood]

Details, e.g. Dates, treatments, symptoms

[/group]

Diabetes

diabets

[group diabets]

Details, e.g. Dates, treatments, symptoms

[/group]

High cholesterol

cholesterol

[group cholesterol]

Details, e.g. Dates, treatments, symptoms

[/group]

Heart disease including heart attack, coronary artery disease and chest pain

heart disease

[group heart disease]

Details, e.g. Dates, treatments, symptoms

[/group]

Arthritis

arthritis

[group arthritis]

Details, e.g. Dates, treatments, symptoms

[/group]

Depression

depression

[group depression]

Details, e.g. Dates, treatments, symptoms

[/group]

Anxiety

anxiety

[group anxiety]

Details, e.g. Dates, treatments, symptoms

[/group]

Epilepsy

epilepsy

[group epilepsy]

Details, e.g. Dates, treatments, symptoms

[/group]

History of seizures or convulsions

seizures or convulsions

[group seizures or convulsions]

Details, e.g. Dates, treatments, symptoms

[/group]

Thyroid problems

thyroid

[group thyroid]

Details, e.g. Dates, treatments, symptoms

[/group]

Stroke

stroke

[group stroke]

Details, e.g. Dates, treatments, symptoms

[/group]

Osteoporosis/Osteopenia

osteoporosis

[group osteoporosis]

Details, e.g. Dates, treatments, symptoms

[/group]

Seasonal Allergies

allergies

[group allergies]

Details, e.g. Dates, treatments, symptoms

[/group]

Migraines

migraines

[group migraines]

Details, e.g. Dates, treatments, symptoms

[/group]

Eye problems

eye problems

[group eye problems]

Details, e.g. Dates, treatments, symptoms

[/group]

Hearing problems or Deafness

deafness

[group deafness]

Details, e.g. Dates, treatments, symptoms

[/group]

Liver problems, including Hepatitis B or C

liver problems

[group liver problems]

Details, e.g. Dates, treatments, symptoms

[/group]

Kidney problems

kidney problems

[group kidney problems]

Details, e.g. Dates, treatments, symptoms

[/group]

Cancer

cancer

[group cancer]

Details, e.g. Dates, treatments, symptoms

[/group]

Stomach or intestinal conditions

stomach

[group stomach]

Details, e.g. Dates, treatments, symptoms

[/group]

Gastric Bypass

gastric

[group gastric]

Details, e.g. Dates, treatments, symptoms

[/group]

Irritable Bowel Syndrome

irritable

[group irritable]

Details, e.g. Dates, treatments, symptoms

[/group]

Skin conditions or diseases

skin conditions

[group skin conditions]

Details, e.g. Dates, treatments, symptoms

[/group]

Special Dietary Requirements (lactose intolerance, vegetarian, other:)

special dietary

[group special dietary]

Details, e.g. Dates, treatments, symptoms

[/group]

Asthma

asthma

[group asthma]

Details, e.g. Dates, treatments, symptoms

[/group]

Respiratory Problems

Have you had any surgeries in the past 10 years, or major surgeries in your life?

YesNo

Do you have any allergies to any foods, medications or other substances such as latex or imaging dye?

YesNo

If yes, please list type and date of surgery

Social Drug Use

Do you smoke or use tobacco products?

YesNo

Cigarettes

[group Cigarettes]

How many

[/group]

Cigars

cigars

[group cigars]

How many

[/group]

Other

other

[group other]

Details

[/group]

Do you drink alcohol?

YesNo

If yes how many alcoh

For males only

Have you had a vasectomy? *

YesNo

If so what year?

For females only

Please check any of the following that apply to you (or None at the bottom of the list)

Tubes tied

tube

[group tube]

Year

[/group]

Hysterectomy

hysterectomy

[group hysterectomy]

Year

[/group]

Removal of ovaries (without a hysterectomy)

removal of ovaries

[group removal of ovaries]

Year

[/group]

Have you been through the menopause?

YesNo

When was your last menstrual cycle?

Are you using hormonal replacement theraphy (HRT)?

YesNo

If yes, name of treatment

YesNo

None

none

[group none]

What type of contraception do you use?

Please specify the brand name

How long have you been taking it?

[/group]

General Information

If needed for a study, would you be able to obtain your medical records?

YesNo

Emergency contact name

Emergency contact phone

I have read and agreed to the ICON Data Protection Policy

agree

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