Questionnare for Volunteers

Personal data

Name*
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Surname*
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Address*
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Location/Town*
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County*
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Gender*
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Date of birth*
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Weight (in kg)*
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Height (in cm)*
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Do you smoke?*
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Phone no.
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Mobile no.*
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E-mail address*
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Verify e-mail address*
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Have you ever participated in a clinical study as a volunteer?

Tell us in a few words your experience, mentioning the last time you were recruited to participate in a study.

Your experience
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Medical data

Chronic disease*
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Respiratory*
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Cardiovascular*
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Liver*
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Gastrointestinal (digestive)*
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Urogenital*
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Rheumatologic*
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Other*
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Agreement and signature

I hereby declare that the data listed above is real. I am aware of the fact that this document was completed electronically and does not require another signature.

Signature (Name and surname)*
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Date*
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Code
Code
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