RocheUK.com - Patient Volunteer Studies Electronic Form

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Please fill in the following contact details if you are interested in participating in a clinical trial at Roche Applied Clinical Development Unit (ACDU) in Welwyn. Thank you for your interest in Roche

Title:
If Other, specify:
Surname:
Forename:
Date of birth:

Address:

City:
County:
Postcode:

Home Tel:
Work Tel:
Mobile Tel:
Email:

GP Name:
Consultant & hospital name:

Height:	feet	inches
Weight:

Questionnaire:
1. I suffer from the following condition(s):
Please give details:
	(e.g. how long since you were diagnosed with this condition? any complications?)

2. In the past have you ever suffered from or are you currently suffering from: TB, Hypertension (high blood pressure), Rheumatic Fever, Epilepsy, MI (Heart Attack), Jaundice, Deep Vein Thrombosis, Pulmonary Embolism, Gastric or Duodenal ulcer?

Yes No

Please give details:
	(e.g. how long since you were diagnosed with this condition? any complications?)

3. Do you have any allergies: drug / food / hayfever / skin problems / other?

Yes No

Please give details:
	(e.g. type of allergic reaction and when?)

4. Have you ever been admitted to hospital?

Yes No

When, where & why?

5. Are you on any regular medication?

Yes No

Please give details:
	(e.g. name, dose & frequency)

6. Do you smoke?

Yes No

Many cigarettes/cigars or pipes a day?

7. How many units of alcohol do you drink per week? (one unit = half pint of beer, one small glass of wine or one measure of spirits)

8. Have you participated in clinical studies in other centres?

Yes No

Date of last participation?

9. How did you hear about us?
If Other, specify:
If referred by a friend, please include their full name as you may be entitled to receive a “refer a friend” bonus

I am interested in becoming a volunteer with a view to participating in a study. Please send me details of relevant studies when available.

I consent to the information I have provide herein being retained on file by Roche Products Limited, ACDU, Welwyn to assess my suitability as a volunteer and understand that should my application not be successful these details will be destroyed. I also understand that if I do not attend a medical at Roche within the next 60 days, the personal details that have I provided will be destroyed.