Registration Form - San Antonio

This sends us your information, so you can be added to our database.  It does not schedule you an appointment.

Fields market with an * symbol are mandatory.

 
 
Gender *   
Age
cm
kg
lbs
BMI
Are you currently taking any medication? *   
Please check any of the following conditions that apply to you:
High blood pressure
Low blood pressure
Diabetes
Type 1 or Type 2 diabetes? *   
Do you have diabetic neuropathy? *   
Do you have diabetic retinopathy? *   
High cholesterol
Heart disease including heart attack, coronary artery disease and chest pain
Arthritis
Please indicate the type of arthritis *
Depression
Anxiety
Epilepsy
History of seizures or convulsions
Thyroid problems
Stroke
Osteoporosis/Osteopenia
Seasonal Allergies
Migraines
Eye problems
Glaucoma? *   
Hearing problems or Deafness
Liver problems, including Hepatitis B or C
Kidney problems
Cancer
Stomach or intestinal conditions
Gastric Bypass
Irritable Bowel Syndrome
Skin conditions or diseases
Special Dietary Requirements (lactose intolerance, vegetarian, other:)
Asthma
Do you use medication to treat your asthma? *   
How often do you use medication to treat your asthma?
Have you had any surgeries in the past 10 years, or major surgeries in your life? *   
Do you have any allergies to any foods, medications or other substances such as latex or imaging dye? *   

Social Drug Use

Do you smoke or use tobacco products? *   
Cigarettes
Cigars
Other
Do you drink alcohol? *   

For males only

Have you had a vasectomy? *   
If so what year?

For females only

Please check any of the following that apply to you (or None at the bottom of the list)

Tubes tied
Year:
Hysterectomy
Year:
 
Removal of ovaries (without a hysterectomy)
Year:
Have you been through the menopause?   
When was your last menstrual cycle?
Are you using hormonal replacement theraphy (HRT)?   
If yes, name of treatment
None
What type of contraception do you use?
Please specify the brand name
How long have you been taking it?

General Information

If needed for a study, would you be able to obtain your medical records? *   
Please enter the characters above:*

Check your BMI

Check your BMI here with our body mass calculator.

Units:
Your Height:
(cm)
Your Weight:
(kg)
Your Height:
Your Weight:
lbs
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