Today M-D-Y
First Name: *
* must provide value
Middle: *
* must provide value
Last Name: *
* must provide value
Date of Birth Month: *
* must provide value
January February March April May June July August September October November December
Date of Birth Day: *
* must provide value
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Date of Birth Year: *
* must provide value
2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Gender: *
* must provide value
Female Male
Participant's Height Feet: *
* must provide value
2 3 4 5 6 7 8
Example: If your height is 5'7", enter 5 in this box and 7 in the next box.
Participant's Height Inches: *
* must provide value
1 2 3 4 5 6 7 8 9 10 11
Example: If your height is 5'7", enter 5 in the previous box and 7 in this box.
Participant's Weight:
* must provide value
whole number
Parent/Legal Guardian's First Name: (If completing form for a minor) *
Required only if the participant is a minor.
Parent/Legal Guardian's Last Name: (If completing form for a minor) *
Required only if the participant is a minor.
Street Address: *
* must provide value
City: *
* must provide value
State: *
* must provide value
AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WY
Zip: *
* must provide value
Preferred Phone Number: *
* must provide value
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
American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White or Caucasian More than one race
Hispanic / Latino Non-Hispanic / Non-Latino
Do you use tobacco? DEPRECATED FIELD -- NOT VISIBLE IN SURVEY
No Yes
Are you a twin? DEPRECATED FIELD -- NOT VISIBLE IN SURVEY
No Yes
What is your highest level of education completed?
DEPRECATED FIELD -- NOT VISIBLE IN SURVEY
Some High School Completed High School or GED Some College Bachelors degree Graduate degree
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.
Please list all medications (including over-the-counter drugs) that you are currently taking.
DEPRECATED FIELD -- NOT VISIBLE IN SURVEY
Have you ever been a patient at UNM?
DEPRECATED FIELD -- NOT VISIBLE IN SURVEY
No Yes
(This database is separate from and will not be linked to any UNM medical/health records)
Are you updating information that you previously provided?
No Yes
Would you like to be removed from this registry?
No Yes
Are you giving us a phone/verbal consent?
No Yes
A copy of the consent was mailed to the patients?
No Yes
If you selected "Yes" for "A copy of the consent was mailed to the patient", please enter the date the copy was sent.
Today 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
Submit
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