Patient Registry

As always, answering the following series of questions is completely voluntary and serves to build your profile for inclusion in clinical research studies. The more profile questions you answer, the more specific opportunities we will be able to offer you in the future.

Provident Research will only use your information to provide you with Clinical Trials opportunities and will never sell your information to another party.

Regards,
Julie Wilson, Director of Clinical Services

First Name:	(required)
Last Name:	(required)
Street Address:
City:
State:
Zip Code:	(required)
Phone:	(required)
Email:	(required)
I prefer to be contacted by:	Phone Email No preference
Do you, anyone in your household, or someone for whom you provide care, suffer from any of the following ailments or medical conditions? (Please select all that apply.)
Diabetes, Type 1:	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Diabetes, Type 2:	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
AIDS / HIV:	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Alzheimer's	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Hypertension / High Blood Pressure	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Arthritis (Osteo)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Arthritis (Psoriatic)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Arthritis (Rheumatoid)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Psoriasis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Depression	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Stroke	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
COPD	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
ADD / ADHD	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Allergies	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Irritable Bowel Syndrome (IBS)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Crohn's Disease	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
ALS / Lou Gehrig's Disease	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Multiple Sclerosis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Epilepsy	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Kidney Disease / Renal Failure	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Erectile Dysfunction (ED)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Anemia	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Anxiety	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Autism	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Acne	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Psoriasis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Asthma	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Gout	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Parkinson's Disease	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Hemophilia	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Incontinence	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Hepatitis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Osteoporosis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Shingles	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Fibromyalgia	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Bipolar Disorder	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Schizophrenia	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Insomnia	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Enlarged Prostate / Benign Prostatic Hyperplasia (BPH)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
High Cholesterol	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Overactive Bladder / Urge Incontinence	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
GERD / Acid Reflux	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Deep Vein Thrombosis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Ulcerative Colitis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cystic Fibrosis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Seizures	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Sexual Dysfunction	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Celiac Disease	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cold Sores	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Constipation	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Eczema	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Anthracnose	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Genital Herpes	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Hearing Loss	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Heartburn	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Hyperthyroidism	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Hypogonadism (Men)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Hypogonadism (Women)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Hypothyroidism	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Infertility	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Lupus	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Menopause	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Migraines	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Muscular Dystrophy	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Nail Fungus	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Obesity	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Organ Transplant (any type)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Restless Legs Syndrome (RLS)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Rosacea	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Sleep Apnea	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Urinary Tract Infections	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Heart Conditions	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Endometriosis	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Narcolepsy	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Arthritis (Large Joint)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Anal	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Bladder	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Bone	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Brain	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Breast	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Cervical	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Colon / Colorectal	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Esophageal	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Kidney (Renal Cell)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Leukemia	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Liver	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Lung	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Melanoma	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Mouth	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Multiple Myeloma	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Non-Hodgkin's Lymphoma	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Ocular	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Ovarian	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Pancreatic	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Penile	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Prostate	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Skin (Non-Melanoma)	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Stomach	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Testicular	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Thyroid	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Uterine	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer
Cancer: Other	I suffer from Someone in my household suffers from I provide care for someone who suffers from Prefer not to answer