ID #: __________ QUINTILES STUDY PARTICIPATION APPLICATION Date Rcvd: _____________

(Internal Use Only) (Internal Use

Only)

Legal First Name: Nayeli Last Name: Guevara Middle Initial: Jr., Sr., II, III

Social Security #:512-17-2981 Birth Date:8-3-1990 Race: Hispanic Gender: Male Female
Current Address: 4615 w. portland City: springfiel d State: mo Zip:65802

Daytime Phone: 417-655-0319 Evening Phone: same E-Mail Address: eanimus999@hotmail.co m

How did you hear about Quintiles? (Check only the one that prompted you to fill out this application)

Personal referral Name: Internet / email

TV Radio (Please indicate station): Newspaper or Publication:

Outreach Event (Please indicate event and approximate date):

Height: 5'8 Weight:125 Frame Size: Small Medium Large Right Handed Left Handed
Do you presently use tobacco? No Yes If yes, # smoked/chewed per day: Duration of tobacco use in # of years:
Have you used tobacco in the past? No Yes If yes, # smoked/chewed per day: Duration in years:       Date quit:
Do you consume caffeine? No Yes If yes, # of caffeine drinks per day: (Cola, Coffee, Tea, or Chocolate)

Do you drink alcohol? No Yes If yes, # of alcohol drinks per week:

Do you have a history of drug or alcohol problems? No YesDate of treatment:

Do you presently use illicit drugs? No Yes Date of last use:

(Marijuana, cocaine, crack, etc.)

Date of last Blood Donation: 05/08 Date of last Plasma Donation:

FEMALE ONLY

Are you of child bearing potential? No Yes Date of last menstruation:

Method of birth control: abstinenc e Date of last Pap Smear:

Name of Emergency Contact: Rosa Geuvara Phone #: 417-849-6565

Are you allergic to any drugs, foods, animals or plants? No Yes If yes, please explain:
When did your allergy begin? Types of reactions:

Are you on any type of prescription or routine over the counter medications? No Yes If yes, please list below:
HOW
HOW START STOP
NAME OF MEDICATION MUCH REASON FOR TAKING
OFTEN DATE DATE
(MGS)
Please mark ( ) any condition for which you have ever been diagnosed or treated by a physician. Remember to list
the date the condition began and provide specific details at the bottom of page.
AUDITORY SYSTEM GASTROINTESTINAL cont. REPRODUCTIVE - MALE
Hearing Loss Liver Disorders Infertility FORMTEXT
Dizziness Irritable Bowel Impotence
Other Other Vasectomy
Other
CANCER HEMATOLOGIC
Type: Anemia REPRODUCTIVE - FEMALE
Blood Clotting Problems PMS
CARDIOVASCULAR Sickle Cell Endometriosis
Angina Other FORMTEXT Vaginal Infections
Coronary Art. Ds. Tubal Ligation
CHF IMMUNE SYSTEM Total Hysterectomy
High Cholesterol HIV With Ovaries Removed
Stroke Auto-immune Disease Partial Hysterectomy
Hypertension Hepatitis B Vaccine Post Menopausal
Heart Attack MUSCULOSKELETAL Other
Abnormal ECG Head Injury
Other Osteoarthritis RESPIRATORY
Rheum. Arthritis Asthma
ENDOCRINE Osteoporosis Adult
Diabetes Childhood
Hypo-thyroid Bronchitis
Hyperthyroid NERVOUS SYSTEM Emphysema
Obesity Migraine Hay fever/Sinus
Other Multiple Sclerosis Other
Parkinson’s
EYE Seizure Disorders
SKIN & SOFT TISSUE
Cataracts 03/07 Alzheimer’s
Acne
Glaucoma Other
Hair Loss
Visual Acuity PSYCHE Eczema
Other Memory Loss Psoriasis
Depression Other
GASTROINTESTINAL Manic Depression
Diarrhea Schizophrenia URINARY SYSTEM
Constipation Sleep Disorders
Kidney Stones
Ulcer Anxiety Disorders
Kidney Infections
Colitis Addictive Disorders
Renal Failure
Gall Bladder Other
Other

For each category checked above, please provide the additional information below:

TYPE OF TREATMENT IS THE CONDITION

DIAGNOSIS DATE DIAGNOSED
RECEIVED STILL PRESENT?
yes
FORMTEXT      
02-1998 eye glasses
FORMTEXT astigmatism

FORMTEXT      
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Have you ever been hospitalized, had emergency room treatment, surgery of any type or any other medical problems? No Yes
Please describe:

FORMTEXT
FORMTEXT

Revised 6/20/04