Submission Form

Complete only the questions that you are comfortable filling out online in order to qualify.

*Required Fields
*Patient Name:		*Age:		*City:		*State:

*Phone (H):

Phone (W):

Phone (C):

Have you participated in another clinical study with an investigational agent or device within the last 30 days?	Yes No
Have you been treated for GI malabsorption?	Yes No
Have you donated blood or plasma within the last 4 weeks?	Yes No
Have you been diagnosed with any joint disease?	Yes No
Have you had cancer within the last 5 years?	Yes No
Do you have any heart, lung, liver, kidney, or blood disorders that are unstable?	Yes No
Do you have a history of heart attack, heart surgery, or onset of new chest pains within the last 6 months?	Yes No
Do you have a history of gastrointestinal bleeding within the last 5 years?	Yes No
Do you currently take asprin for the cardiac benefits?	Yes No

Current Medications:

Medication	Condition	Dose/Freq	Start Date

Drug Allergies:

Medication	Date

Ongoing Medical Conditions:

Medical Condition	Start Date	Active
		Yes No
		Yes No
		Yes No
		Yes No
		Yes No
		Yes No

Surgeries or Procedures:

Surgeries	Medical Condition Treated	Date

After reviewing the online questionnaire, we will follow up with you by phone.