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Medical History Survey
To include you in a suitable Clinical trial, we would like to have more information about your medical history.
GET STARTED
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.
Name
Surname
Age
Gender
Email
Phone number
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 Disorders:
Stroke
Migraine
Tension Headaches
Insomnia
Epilepsy
Parkinson's Disease
Multiple Sclerosis
Restless Leg Syndrome
Alzheimer's Disease
Imunological:
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
Submit
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