Submit an Application Today To be eligible to participate in a clinical research study, simply submit an application. 12345 Have you previously submitted an application? Yes No Please call your recruiting office at 305-665-5151 to update your application with a recruiting team member or let them know of your interest in a study. Full Legal Name (As it appears on your Social Security Card)* First Middle Last Date of Birth* MM slash DD slash YYYY What is your gender?* Male Female Race*WhiteBlackAmer. IndianAsianAlaskaHawaiianPacific IslanderHispanic Ethnicity:* Yes No Height (Feet)*Height (Inches)*Weight (lbs.)*BMI*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone #*Alternate Daytime #Work Phone #*By providing your mobile phone number, you are giving consent to send you text messages and/or automated calls regarding clinical research trials. Your cellular provider's message and data rates may apply. Please notify us immediately if you change mobile numbers or plan to provide your phone to another person.Email* Enter Email Confirm Email *By providing your email address, you expressly consent to receive emails from us.Are you able to read, write and comprehend without the help of others?* Yes No Women OnlyMethod of birth control:* Last menstrual cycle date:* MM slash DD slash YYYY Cycle Length (# of days):Menses Length (# of days):*Are you pregnant?* Yes No Plan to become pregnant?* Yes No Nursing or breastfeeding? Nursing Breastfeeding N/A Section BreakNo. of alcoholic drinks* Frequency* daily weekly monthly yearly Do you currently use any tobacco products?* Yes No What type? Menthol Cigarettes Non-menthol Cigarettes Chew E-vapor Cigars Loose/pipe Pouch Moist Snuff Dry Snuff Quantity (i.e., 1/2 pack, 1 can, 2 cigars, 1 pipe, etc.) Frequency daily weekly monthly yearly Has a QPS participant referred you?* Yes No Name of the participant who referred you First Last Select how you heard about QPS Miami* Radio Station - Z 92.3 FM Radio Station - El Zol 106.7 FM Radio Station - Ritmo 95.7 FM Radio Station - Amor 107.5 FM Radio Station - TU 94.9 FM Radio Station - Exitos 107.1 FM Radio Station - Hits 97.3 FM Radio Station - Mix 98.3 FM Radio Station - Jamz 99.1 FM Radio Station - The Beach 102.7 FM Radio Station - The Beat 103.5 FM Radio Station - Big 105.9 FM Radio Station - Mambi 710 AM Radio Station - Caracol 1260 AM Radio Station - Actualidad 1040 AM TV - Telemundo Ch 51 TV - Univision Ch 23 TV - WSVN Ch 7 Google / Search Engine YMCA Bulletin Board Facebook Snapchat Instagram Email Received Word of Mouth Which study are you currently most interested in? Any study available at QPS Miami Study 2101 Medical History Question ListThis questionnaire pertains to your entire medical history from the time you were born until now. Please read this carefully and be as thorough as possible. Remember to give details, details, details, such as start and stop dates, or list the approximate date – month and/or year, if known. Be aware you may be asked to elaborate on some medical history to ensure your safety for participation. You can update your medical history when changes occur in the future at any time by simply speaking with a recruiter. Remember to be honest and truthful about your medical history as this determines the type of clinical research trial you may qualify for. List any food (i.e., peanuts, tomatoes, etc.) drug (i.e., aspirin, Penicillin, etc.) or environmental allergies (i.e., latex, pollen, pet dander, etc.) and the reaction you had to each along with the severity of the reaction.Include the dates of your first and last reaction and whether the allergy was physician diagnosed and/or treated.List any current medications, including over-the-counter products (i.e., vitamins or herbals, etc.). List the date you started them, the reason why and the dosage and frequency (i.e., Prozac for depression, 40 mg, once a day).If you have been vaccinated for Hepatitis B, please also include the dates you received each injection (series of 3).Check any conditions that apply to you (past or present).Cardiovascular (Heart)/Circulatory Chest pains High blood pressure Heart attack Heart murmur Mitral valve prolapse Heart palpitations Blood disorder Heart arrhythmia Anemia Stroke Blood clots High cholesterol Integumentary (Skin) Eczema Psoriasis Rosacea Atopic Dermatitis Significant Visible Scars Tattoos Endocrine Thyroid disease Diabetes Hypoglycemia Pancreatitis Parathyroid disease Adrenal disorders Polycystic ovarian syndrome Hashimotos disease Eyes, Ears, Nose and Throat Hearing impairment Cataracts Glaucoma Deviated septum Sleep apnea Repeated ear infections Repeated throat infections (strep or tonsillitis) Gastrointestinal Frequent vomiting Ulcers GERD (acid reflux) IBS/spastic colon Diverticulosis Bowel obstruction Crohn’s disease Ulcerative colitis Celiac disease Diarrhea Constipation Hepatic Liver disease Jaundice Hepatitis (+ test) Cirrhosis Gilbert’s syndrome Gallbladder disease Genitourinary Abnormal pap smear Enlarged prostate Kidney stones Prolapsed uterus Kidney disease Fibroid tumors Overactive bladder Hemorrhoids Frequent urinary tract infections Ovarian cysts Immune/ Systemic HIV (+ test) Lyme disease Polio Lupus Rheumatic fever Meningitis Rheumatoid arthritis Musculoskeletal Arthritis Osteoporosis Fibromyalgia Tremors Gout Tendonitis Carpal tunnel Bunions Herniated discs Torn ligaments/tendons Neurological Migraines Concussion Frequent headaches Dizziness Head trauma Loss of consciousness Epilepsy Seizures Fainting ADD/ADHD Multiple sclerosis Psychological Anorexia Obsessive compulsive disorder Depression Anxiety Bipolar disorder Alcohol abuse Drug abuse Bulimia Respiratory Asthma Emphysema COPD TB (+ test) Miscellaneous/Other Cancer Coma Tumors Insomnia Cysts I confirm that the information provided on this application is, to the best of my knowledge, complete and accurate. I confirm that I have read and expressly consent to provide my personal information to QPS Miami in accordance with these terms and conditions. I understand that this information will be used for the sole purpose of determining my eligibility to volunteer for a clinical research trial. I understand that QPS Miami will use its best efforts to treat my information provided in this registration form with security and confidentiality. The contact information I provide may be retained in a database owned by QPS Miami. I consent to be contacted by QPS Miami and its service providers via email, phone or text message and that standard usage rates may apply. I confirm that I am 18 years or overDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
