Prescreening Questionnaire – Clinilabs Drug Development Corporation

First Name*

Last Name*

Mobile Phone*

Email*

What was your biological sex assigned at birth?*

To which gender identity do you most identify?*

What are your preferred pronouns?

How Old Are You?*

What is your race?*

Do you have any major medical conditions?*

Are you fully vaccinated for COVID-19?

Please check off any substance(s) you use:

Which research facility are you willing to travel to?*

Are you available to come in for a screening visit this week?*

Have you ever participated in a clinical research study before?

Do We Have Your Permission to Contact You by phone, text or email? You may remove your information from our database at any time.*