Clinical Trials, Medical Research, Investigational Drug Studies, Clinical Trials Charleston, medical research Charleston, Coastal Carolina Research Center Charleston South Carolina

If you are interested in being considered for one of our studies in the future please fill out the form below. We will contact you before we begin the next study.

* required fields

* Name:
* Email:
* Telephone:	(H) (W) (C)
* Address:
* City:	* State * Zipcode
* Date of Birth:		* Race:
* Height:		* Weight:
* Contact Preferences?
* Smoker:		How much per day:
* Drinker:		How much per week:
* Which office would you choose to participate at?		##NEXT_STUDY_WHICH_OFFICE##
* What types of research studies would you be interested in:

To help us better serve you and place you in appropriate studies, please complete the following health information. The below information is voluntary and you do not have to answer anything that you do not choose. This information will be kept confidential and only used for the purposes of study determination.

Insomnia?
HIV/AIDS?
Seasonal allergies?
High Cholesterol?
Thyroid problems?
Diabetes?
Depression or anxiety?
Migraines?
High Blood Pressure, heart conditions or surgery?
If yes, explain:

Liver Problems(cirrhosis, hepatitis, etc)?
If yes, explain:

Kidney Problems(stones, impaired function)?
If yes, explain:

Lung Conditions(asthma, COPD, chronic bronchitis)?
If yes, explain:

Cancer?
If yes, where and when:

Neurological conditions(seizures, Parkinson's, restless legs syndrome, neuropathy)?
If yes, explain:

Musculoskeletal problems(arthritis, bulging disks, osteoporosis)?
If yes, explain:

Stomach problems(GERD, IBS, Crohn's, diverticulosis, etc)?
If yes, explain:

Are you allergic to anything(medications, food, insects, etc) ?
If yes, explain:

Any problems with your eyes, ears, nose or throat?
If yes, explain:

Skin Conditions(eczema, psoriasis, rosacea, cold sores, nail fungus)?
If yes, explain:

Urological problems(over active bladder, incontinence, etc)?
If yes, explain:

Have you had any surgeries?
If yes, please list with approximate dates:

Do you suffer with any other health conditions not mentioned above:

What medications are you taking including herbals and over the counter?
Medication	Dosage	How often	Date started

Do we have permission to add your information to our confidential database? We do not share this information with anyone outside of our organization.
* [If no]: We will destroy this information if you do not qualify for participation.

The Lowcountry's Resource for Medical Research