Medical History survey
 

By completing this survey, we will be able to determine if there are a suitable study currently at JOHESE.  Your details will be added to a database and you will be contacted in future should a suitable study for your condition starts in Centurion.

We will keep your data confidential.

  * Fields are mandatory
  * Please complete the fields below:
     
  Name:
  Surname:
  Age
  Gender
  Email:
  Contact:
     
  To include you in a suitable Clinical trial, we would like to have more information about your medical history. Either tick your conditions below or you can tell us about your Medical history in the field below.
   
 
   
  CARDIOVASCULAR DISORDERS
     
  High Blood Pressure
  Angina
  Heart Attack
  High Cholesterol
  Bypass / Stent / Pacemaker
  Statin Intolerant
     
  BLADDER/KIDNEY DISORDERS
     
  Kidney Stones
  Kidney Failure without Dialysis
  Kidney Failure with Dialysis
  Frequent Urinary Tract Infection
     
  METABOLISM
     
  Type I Diabetes
  Type II Diabetes
  Thyroid Disorder
     
  PULMONARY DISORDERS
     
  Childhood Asthma
  Asthma
  COPD
  Chronic Bronchitis
     
  MUSCOSKELETAL DISORDERS
     
  Osteoarthritis
  Osteoporosis
  Fractures
  Back Pain
  Gout
     
  DIGESTIVE SYSTEM DISORDERS
     
  IBS
  Constipation
  Crohn's Disease
  Peptic Ulcer
  Heart Burn
  Ulcerative Colitis
     
  CENTRAL NERVOUS SYSTEM
     
  Stroke
  Migraine
  Tension Headaches
  Insomnia
  Epilepsy
  Parkinson's Disease
  Multiple Sclerosis
  Restless Leg Syndrome
  Alzheimer's Disease
     
  IMMUNOLOGICAL
     
  Rheumatoid Arthritis
  Hay Fever
  Chronic Rhinitis
  Allergies
     
  SKIN
     
  Eczema
  Dermatitis
  Psoriasis
  Athletes Foot
  Shingles
     
  EYES
     
  Dry eyes
  Glaucoma
  Macular Degeneration
  Cataracts
     
  PSYCHIATRIC
     
  Depression
  Anxiety
  OCD
  Eating Disorders
     
  LIVER DISEASE
     
  Hepatitis B
  Hepatitis C
  Liver Cirrhosis
  Liver Transplant
     
  FEMALE
     
  Hysterectomy
  Ovaries removed
  Hormone replacement therapy
  Post menopausal
  Hot flushes
     
  MALE
     
  Prostate disease
  Difficulty passing urine
     
  CANCER
     
  Current
  Metastatic
  Recurrent
  Under treatment
     
  LIFESTYLE
     
  Smoking
     
  PREFERRED LANGUAGE
     
  English
  Afrikaans
     
  Are you willing to travel to Centurion to participate in a study?
     
  Yes
  No