Study Hotline (305) 665-5151
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QPS Miami Research Center of Excellence
Study Hotline (305) 665-5151
enrollingstudies@qps.com
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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
*
Date Format: MM slash DD slash YYYY
What is your gender?
*
Male
Female
Race
*
White
Black
Amer. Indian
Asian
Alaska
Hawaiian
Pacific Islander
Hispanic Ethnicity:
*
Yes
No
Height (Feet)
*
Height (Inches)
*
Weight (lbs.)
*
BMI
*
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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Ohio
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South Carolina
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Tennessee
Texas
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Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed 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 Only
Method of birth control:
*
Last menstrual cycle date:
*
Date Format: 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 Break
No. 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 List
This 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 over
Date
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