DEMOGRAPHIC AND HEALTH QUESTIONNAIRE - Vida Clinical Research Forms

PATIENT INFORMATION

Name

First

Last

Phone

Email

Cell Phone

Social Security Number

Date of Birth

Age

Gender (select one)

Complete Mailing Address including zip code

Address Line 1

Address Line 2

City

State

Zip Code

Military Service:

Army
Navy
Air Force
Marines

Your Occupation

What shift do you work?

Days
Nights
Weekends Only

Employer

Employer Phone

Number of Years in Service

Known Exposure

In Case of Emergency (Name of local friend or relative not living at the same address)

1.

2.

Relation to You

Phone

Marital status

Married
Single
Divorced
Widowed

# of Living Children

# of Pregnancies (women)

PERSONAL HEALTH HISTORY

Childhood Ilness

Immunizations and Dates

Tests / Screening and Dates

Checkboxes

Eye Exam

Dates

Checkboxes

Colonoscopy

Single Line Text

Checkboxes

DXA Scan

Dates

Checkboxes

Chest Xray

Single Line Text

Checkboxes

Mammogram

Single Line Text

Surgeries

Year

Reason

Hospital

Year

Reason

Hospital

Year

Reason

Hospital

Year

Reason

Hospital

Year

Reason

Hospital

Hospitalizations

Year

Reason

Hospital

Year

Reason

Hospital

Year

Reason

Hospital

Year

Reason

Hospital

Year

Reason

Hospital

Checkboxes

I have Never Been Hospitalized

Have you ever had a Blood Transfusion?

Yes
No

Date

MEDICAL HISTORY

History / Condition

Alcohol Abuse

Date Diagnosed

History / Condition

High Blood Pressure

Date Diagnosed

ANY OTHER MEDICAL HISTORY

Condition

FAMILY MEDICAL HISTORY

ANY OTHER HISTORY

Condition

Present

Yes
No

Onset Date

Resolution Date

-

ongoing

Condition

Present

Yes
No

Onset Date

Resolution Date

-

ongoing

SOCIAL HISTORY

GYNECOLOGY HISTORY

PREGNANCY HISTORY

Entries Top to Bottom

-

Never Been Pregnant

Year

Place of delivery or abortion

Duration Preg.

Hrs of Labor

Type of Delivery

Complications / Mother or Infant

Sex

Birth Weight

Present Health

Year

Place of delivery or abortion

Duration Preg.

Hrs of Labor

Type of Delivery

Complications / Mother or Infant

Sex

Birth Weight

Present Health

Year

Place of delivery or abortion

Duration Preg.

Hrs of Labor

Type of Delivery

Complications / Mother or Infant

Sex

Birth Weight

Present Health

Year

Place of delivery or abortion

Duration Preg.

Hrs of Labor

Type of Delivery

Complications / Mother or Infant

Sex

Birth Weight

Present Health

Additional Pregnancies

BIRTH CONTROL HISTORY

What birth control method(s) do you currently use?

Checkboxes

None

Comments

By signing below, I acknowledge that the information I have given above is accurate and true. I realize that giving false information could result in serious harm to me and could possibly alter the results of the research trial that I wish to participate in.

Patient Signature

Clear Signature

Date

Reviewed By

Clear Signature

Date

Clinical Trial Participation Questionnaire

Participant Information

1. Full Name

First

Last

2. Age

3. Gender

Male
Female
Non-Binary
Prefer not to say

4. Contact Information

Phone

Email

Health and Medical History

1. Do you have any chronic conditions? (e.g., diabetes, hypertension)

Yes
No

If yes, please specify: (copy)

2. Are you currently taking any medication?

Yes
No

Resolution you

If yes, please list:

3. Have you participated in a clinical trial before?

Yes
No

4. Do you have any known allergies or adverse reactions to medications?

Yes
No

If yes, please describe

Understanding of the Trial

1. How did you hear about this clinical trial?

Social media
Medical professional referral
Family/Friend
Other

Other (please specify):

2. Do you understand the purpose of this clinical trial?

Yes
No

3. Have you reviewed the Informed Consent Form?

Yes
No

Motivations and Concerns

1. What motivates you to participate in this clinical trial? (select all that apply)

Other (please specify):

2. Do you have any concerns about participating in this trial?

Yes
No

If yes, please specify:

3. What factors are most important to you in deciding to participate?

Availability and Preferences

1. Are you able to attend all scheduled appointments for the trial?

Yes
No

2. Do you have any scheduling preferences or restrictions?

3. Do you prefer in-person visits or remote consultations?

In-person
Remote

Describe

Feedback

1. Do you have any suggestions or additional comments regarding this clinical trial or the process?

Thank you for your time and interest in participating in this clinical trial! Your input is valuable to us.

Clinical Trial Prior Participation

Have you ever participated in a clinical trial before?

Yes
No

If yes, how many clinical trials have you participated in?

When was your most recent participation in a clinical trial?

Date

What motivated you to participate in a clinical trial?

How would you rate your overall experience with clinical trials? 1 be the worst 10 be the best.

Selected Value: 0

What challenges, if any, did you face during your participation?

Did you feel adequately informed about the clinical trial before participating?

Yes
No

Would you consider participating in a clinical trial again in the future?

Yes
No

If no or unsure, what concerns do you have about future participation?

What factors would encourage you to participate in future clinical trials?

Additional Feedback

Do you have any additional comments or suggestions regarding your experience with clinical trials or future participation?