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m3bvDSNrwkgGgNpeKICW48kHaDrJej3AdpdABJioudhNSLj3xGHXs7L6KK4tXnEdqppypd2BFb8FXtDXnSfFawE3PyRcfzrAKLFzQhYrG3rWQWE9ezoFCvUj3y

Clinical Research Volunteer Registry

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Thank you for your interest in volunteering for research studies at the University of New Mexico's Clinical and Translational Science Center. Fill out and submit this form to volunteer for possible participation in any research study, now or in the future.

Filling out this form in no way obligates you to participate in any study. It informs researchers of your interest and provides them necessary information to match your profile with the needs of a particular study. The researchers will then contact you directly by phone or e-mail assessing your interest and suitability for a particular study. Participation in clinical research studies is voluntary, and requires visits to the University of New Mexico's Clinical and Translational Science Center in Albuquerque, New Mexico.

You may modify or withdraw your information at any time by following the directions listed at the bottom of this web page.

A parent or legal guardian may enter information on behalf of a minor (child less than 18 years of age). However, all contact information (Guardian's name, address and phone number) must be completed with the parent or guardian's information.

Hard-copy Date

M-D-Y

First Name: *

* must provide value

Middle: *

* must provide value

Last Name: *

* must provide value

Date of Birth Month: *

* must provide value

Date of Birth Day: *

* must provide value

Date of Birth Year: *

* must provide value

Gender: *

* must provide value

Participant's Height Feet: *

* must provide value

Participant's Height Inches: *

* must provide value

Participant's Weight:

* must provide value

Parent/Legal Guardian's First Name:
(If completing form for a minor) *

Parent/Legal Guardian's Last Name:
(If completing form for a minor) *

Street Address: *

* must provide value

City: *

* must provide value

State: *

* must provide value

Zip: *

* must provide value

Preferred Phone Number: *

* must provide value

Alternate Phone:

Email:

Many trials enroll healthy volunteers as 'control' subjects. Are you in good general health, with no chronic medical conditions? *

* must provide value

Yes--I am in good health (without chronic medical conditions)

No--I currently have a medical condition

reset

Race:

Ethnicity:

Do you use tobacco? DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Are you a twin? DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

What is your highest level of education completed?

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Allergies and Infections

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Allergies (Allergic Rhinitis and Others)

Immune Suppression (non-HIV)

Mast Cell Activation and Mastocytosis

Other Infections

Behavior Related

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Alcoholism

Non-alcohol Drug Abuse & addiction

Other addiction

Smoking Cessation

Blood Disorders

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Blood Cell Cancer (Leukemia/Lymphoma, Bone marrow/Stem Cell Transplant)

Hemophilia

Other Blood Disorders

Sickle cell disease

Cancer

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Bladder and Urinary Tract Cancer (other than Prostate)

Blood Cell Cancer (Leukemia/Lymphoma, Bone marrow/Stem Cell Transplant)

Brain and Neural Cancer

Breast Cancer

Colon Cancer

Gastrointestinal Cancers (Liver, Pancreas, etc.) other than Colon

Gynecological Cancer (Cervix, Utero, Ovaries)

Head and Neck Cancer

Kidney Cancer

Lung Cancer

Melanoma and Skin Cancer

Other Cancers

Prostate Cancer

Solid Tumors (Willms Tumor, Neuroblastoma, Retinoblastoma, Sarcoma)

Thyroid Cancer

Child Health

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

ADHD (Attention Deficit Hyperactivity Disorders)

Autism

Down Syndrome

Learning and Developmental Disabilities

Other Children Diseases

Diabetes, Metabolism and Endocrinology

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Adrenal Disease

Diabetes, type 1

Diabetes, type 2

Diabetes, type unknown

Erectile Dysfunction, Sexual Dysfunction

Growth Abnormalities

Hypogonadism

Obesity and Weight Loss

Osteoporosis

Other Endocrine Conditions

Overactive Thyroid

Pituitary Disease

Pre-diabetes

Reproductive Difficulties

Thyroid Cancer

Underactive Thyroid

Digestive System

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Cirrhosis of the Liver

Colon Cancer

Gastrointestinal Cancers (Liver, Pancreas, etc.) other than Colon

GERD (Heartburn or Gastro Esophageal Reflux Disease)

Inflammatory Bowel Disease (Crohns, Ulcerative Colitis)

Irritable Bowel Syndrome

Liver Diseases, Hepatitis, Liver Transplant

Other Digestive Diseases

Ear, Nose, Throat, Head, Neck

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Ear and Hearing Disorders

Head and Neck Cancer

Sinusitis

Eye Diseases

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Glaucoma

Macular Degeneration and Blindness

Other Eye Diseases

Retinopathy, Diabetic

Retinopathy, Non-diabetic

Heart and Blood Vessels

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Abdominal Aortic Aneurysm

Arrhythmias, Heart Rhythm Problems

Congenital Heart Disease

Congestive Heart Failure

Coronary Artery Disease

Heart Transplant

High Blood Pressure (Hypertension)

High Cholesterol, Hyperlipidemia

Low Blood Pressure and fainting

Other Cardiovascular Disease

Peripheral Vascular Disease, Claudication, Atherosclerosis

Postural Tachycardia Syndrome (POTS)

Infectious Disease and Inflammation

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

HIV/AIDS

Methicillin Resistant Staph Aureus (MRSA)

Other Infections

Sexually Transmitted Diseases

Tuberculosis

Joints, Bone and Muscles

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Back and Joint Surgery (Knee, Hip, etc)

Lupus

Osteoarthritis

Osteoporosis

Other Joints, Bone and Muscle Diseases

Rheumatoid Arthritis

Kidney Diseases

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Chronic Kidney Failure, Dialysis

Diabetic Kidney Disease

Kidney Cancer

Kidney Stones

Kidney Transplantation

Other Kidney Diseases

Lung Diseases

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Asthma

Bronchitis & COPD (Chronic Obstructive Pulmonary Disease), Emphysema

Cystic Fibrosis

Lung Cancer

Lung Transplantation

Pulmonary Fibrosis

Pulmonary Hypertension

Mental Health

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

ADHD (Attention Deficit Hyperactivity Disorders)

Alzheimers Disease and Dementia

Autism

Mood Disorders (Anxiety, Depression, Bipolar disorder)

Other Mental Health

Schizophrenia

Miscellaneous

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Dental Conditions

Nervous System and Brain Disorders

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Alzheimers Disease and Dementia

Brain and Neural Cancer

Cerebral Cavernous Malformations (CCM)

Headache, Migraine and Chronic Pain Management

Movement Disorders (Parkinsons Disease and Others)

Multiple Sclerosis

Other Neurological Diseases

Seizures, Epilepsy

Stroke

Skin Diseases and Plastic Surgery

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Acne

Breast Implants

Cutaneous Lymphoma (CTCL)

Eczema, Atopic Dermatitus

Genetic Skin Conditions

Melanoma and Skin Cancer

Other Skin Conditions

Psoriasis

Skin Boold Vessel Malformations

Vascular Lesions or Malformations in the Skin

Wound Healing, Chronic Ulcers

Urinary Tract Diseases

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Benign Prostatic Hypertrophy (BPH, enlarged prostate)

Bladder and Urinary Tract Cancer (other than Prostate)

Incontinence

Other Urinary Tract Disorders

Overactive Bladder

Prostate Cancer

Women's Health

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Birth Control

Breast Cancer

Endometriosis

Incontinence

Menopause

Pregnancy

Reproductive Problems (Including Infertility)

Uterine Prolapse

Please use this space to list conditions or diseases a doctor has told you that you have. This information is optional, but providing it may help researchers match you with studies that fit you personally.

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Please list all medications (including over-the-counter drugs) that you are currently taking.

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Expand

Please include any additional comments here:

Expand

Have you ever been a patient at UNM?

DEPRECATED FIELD -- NOT VISIBLE IN SURVEY

Are you updating information that you previously provided?

Would you like to be removed from this registry?

Are you giving us a phone/verbal consent?

A copy of the consent was mailed to the patients?

If you selected "Yes" for "A copy of the consent was mailed to the patient", please enter the date the copy was sent.

M-D-Y

By submitting this form, I am allowing my/my child's personal information to be stored in a password protected database with limited access. My/my child's information will be used to determine possible eligibility for participation in a research study through UNM. I understand that enrollment into a research study will be based
on 1) My desire to participate and 2) Meeting eligibility criteria, and 3) At the discretion of the Principal Investigator.

I authorize UNM CTSC to share my/my child's information that has been provided, to principal investigators or their designated research staff, only within the UNM CTSC, and only after they have obtained proper permission from UNM's Human Research Protection Office. My/my child's information will not be shared with anyone outside of the UNM CTSC.

I also agree to be contacted by the UNM CTSC to determine my continued interest in my/my child's
participation as this consent expires 10 years from today's date. I agree to have material sent to me periodically throughout the year with information about my participation and how to contact UNM and the CTSC. Authorization may be revoked by me at any time by any of the following methods:

By writing to:
Mark Burge M.D.
Clinical and Translational Science Center
MSC10-5540
1 University of New Mexico
Albuquerque, New Mexico 87131-0001

By email to: ctsc@salud.unm.edu

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.