Qualia Clinical Services | Research With Results

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Please complete this form or call us at 402.697.6555 to get registered in our database, and to learn more about participating.

Once this form has been submitted, one of our Recruiting Agents will contact you to ask you a few more questions, answer any questions you may have, and see if you qualify for one of our upcoming studies.

We look forward to working with you!

* First Name

Middle Name

* Last Name

* Date of Birth

mmddyyyy

* Sex

Male

Female

* Address 1

* Address 2

* City

* State

* Zip

* Day Phone

Evening Phone

E-mail Address

Height

Weight

* Tobacco Usage:

None (no nicotine w/in the last 90 days)

Cigarettes

			Less than 1 Cigarette/Day
			1 to 10 Cigarettes/Day
			11 to 20 Cigarettes/Day
			1 Pack/Day
			1½ Pack/Day
			2 Packs or more/Day

Chewing Tobacco

Pipe Tobacco

Cigars

Please list any medications you are taking and how long you have been taking it.

Medications:

For How Long:

Please list any significant medical conditions, surgeries, or hospitalizations.