Lillestol Research LLC - Clinical Trials and Research

Fields marked (*) are required.

1. Date 5/22/2013
2. First name *
3. Middle initial *
4. Last name *
5. Address *
6. City *
7. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
8. ZIP code *
9. Date of birth *
10. E-mail *
11. Phone (with area code) *
12. What is your preferred method of contact (Please Note: We highly recommend phone contact)?

    Phone Email
13. Best days/hours to reach you
14. Height
15. Weight
16. Major diagnoses (check all that apply): *

    Acute Coronary SyndromeADHDAllergiesAlzheimer's DiseaseAnemiaAnkle SprainAnxietyArthritisAsthmaAtrial FibrillationBack PainBreast CancerCancer - OtherChronic Kidney DiseaseConstipationCOPDDeep Vein ThrombosisDepressionDiabetes (Type I)Diabetes (Type II)Erectile DysfunctionFemale Orgasmic Disorder (FOD)FibromyalgiaGastric BypassGoutHeart Disease (CHD)High Blood PressureHigh CholesterolHigh TriglyceridesHip FractureHot FlashesHysterectomyInfluenzaInsomniaInterested in a Health Screening?Irritable Bowel SyndromeLow Blood PressureLow CholesterolLow Sexual DesireLow SodiumNoneObesityOophrectomyOsteoarthritisOsteopeniaOsteoporosisOsteoporosis with Vertebral FractureOveractive BladderPeripheral Artery Disease (PAD)Pink EyePulmonary EmbolismRecent Heart AttackRestless Legs SyndromeRheumatoid ArthritisShoulder StrainSinusitisSleep ApneaTendonitis / BursitisVaccineWrist Sprain/Strain

    Other
    If you checked "Other" above, please list all other diagnoses here:
17. Are you postmenopausal?

    Yes No N/A (males)
18. Do you smoke? (Please Note: Smoking does not preclude you from participating in our studies)

    Yes No
19. How did you hear about us? (check all that apply) *

    TV Radio Newspaper Magazine Postcard Flyer/Poster Billboard Physician/Clinic Friend/Relative Email/Internet/Website Facebook Door hanger Newsletter Other
    • Name of friend/relative
    • NOTE: The person who referred you may receive a bonus of $50!
    Please let us know what other way(s) you heard about us:
20. Is there a study in which you are currently interested?
21. Current medications (and dosage, if possible) *
22. Please list any medication allergies you have
23. Primary care physician (if available)
24. Primary care clinic (if available)
25. Additional comments