Research

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Research Participant Application:

Northeast Florida Endocrine and Diabetes Research Center is conducting studies for the following:

If you would like to receive more information about a research study, please select the studies that interest you, complete our questionaire and our staff will contact you.

First Name:

Last Name:

Daytime phone:

Address:

City:

State:

Zip Code:

Email:

Age:

Sex:

Do you have or have you ever had
any of the following medical problems?

(check all that apply)

	Diabetes
	Heart Disease
	High Blood Pressure
	Stroke
	Lung Disease
	Hepatitis B or C
	Cancer
	Kidney Disease

If female, are you currently pregnant, breast-feeding,
or do you plan to become pregnant?

No Yes

Do you currently take any prescription medications?

No Yes (please list medications)