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If you would like to be contacted about participating in a clinical trial, please complete the following form.

* Answers to these questions are required to register.
**One or the other is required.

1. How did you hear about CRI? *

2. First Name *
3. Last Name *
4. Primary Phone Number **
5. Alternate Phone Number
6. Email Address **
7. Date of Birth *
Month
Day
Year ex. 1954
8. What is your gender? *
Female   Male  
9. If female, are you capable of becoming pregnant?
Yes   No  
10. If yes, what type of birth control do you use?

 (i.e. none, abstinence, birth control pills, condom, etc...)
11. What is your race/ethnic background?
12. Have you been hospitalized in the last 5 years?
Yes   No  
13. If yes, for what?
14. What is your height and weight?
What is your height?
Feet:    Inches:

What is your weight?
lbs:
15. Please review the following list of indications and check off any that apply to you
Autoimmune disease
Colitis
Crohn’s disease
Diabetes
Head trauma or injury
Heart attack
Heart disease
Hepatitis
HIV +
Kidney disease
Liver disease
Lung disease
Seizures
Stroke
Do not know
16. Other indications not listed
17. Please check the corresponding boxes below if you are interested in any of the following studies
Adolescent Depression
Adolescent Migraines
Alzheimer’s Disease
Anxiety
Arthritis
Asthma
Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD)
Bipolar Disorder
Cancer
Cognitive Dysfunction
Crohn’s Disease
Decrease in Sex Drive
Depression
Diabetes
Diabetic Neuropathy
Eating Disorder
Endometriosis or Pelvic Pain
Erectile Dysfunction
Fibromyalgia
Gambling Problem
Headaches
Healthy Participant Studies
High Blood Pressure (Hypertension)
Insomnia
Irritable Bowel Syndrome
Manic Depression
Memory Loss
Migraines
Narcolepsy
Neuropathic Pain
Obesity
Osteoarthritis
Osteoporosis
Overactive Bladder
Pain
Parkinson's
Post Herpetic Neuralgia (PHN)
Post Traumatic Stress Disorder (PTSD)
Premature Ejaculation
Premenstrual Syndrome
Schizoaffective Disorder
Schizophrenia
Sexually Transmitted Diseases
Skin Disorders
Smoking Cessation
Social Anxiety
Substance Abuse
Substance Abuse - Alcohol
Substance Abuse - Cocaine
Substance Abuse - Heroin
Substance Abuse - Methamphetamine
Substance Abuse - Pain Killers
18. Other interested studies not listed



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