SUN RESEARCH INSTITUTE 

PATIENT INFORMATION FORM

NAME OF SUBJECT___________________________________________

 Did the Subject  Participate In A Research Trial In The Past 30 Days?    YES OR NO                           

Habits reported:        

Coffee __________________________________      Tea ___________________________________________

Whiskey_________________________________      Beer Or Wine __________________________________

Current Smoker____  Cigarettes   Pipe   Cigars   How Long ___# Yrs    # Cigarettes  Day?______      Pipes & Cigars:  How Often Per Day?____

Previous smoker?  If so, how long ___________  how many cigarettes/pipe/cigars per day____

Date quit_________________

 

Current Medical Conditions And Start Dates .  Include Any Allergies.

1.______________________ ___________________4.  ___________________________________________

2.______________________ ___________________5. ___________________________________________

3.________________________________________  6.  ___________________________________________

 

Surgeries and hospitalizations and dates if  known:

1.____________________________________________4.  __________________________________________

2.____________________________________________5. __________________________________________

3.__________________________________________    6. __________________________________________

 

Medications reported: (to include birth control pills, sleeping aids,  vitamins, any OTC medications, etc

Medication   &  dose                                          Reason for taking                  Date Started     

________________________________            _______________________     ______        

________________________________            _______________________     ______     

 

________________________________            _______________________     ______       

 

________________________________            _______________________     ______      

 

________________________________            _______________________     ______      

 

I acknowledge that I have reviewed this medical form with the above subject and reviewed all  changes/additions  with the subject

 

___________________________________________                           ________________

Study Coordinator                                                                                               Date

 

 

I acknowledge that I have accurately and thoroughly completed this form.  I have discussed all changes/additions with the study coordinator.

 

____________________________________________                        _______________

Signature of Subject                                                                                        Date