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Study Participant
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First
Last
date
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Study Participant address
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State
Zip Code
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Sex
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Male
Female
Birthday
*
Height
*
4 foot 5 inches
4 foot 6 inches
4 foot 7 inches
4 foot 8 inches
4 foot 9 inches
4 foot 10 inches
4 foot 11 inches
5 foot
5 foot 1 inch
5 foot 2 inches
5 foot 3 inches
5 foot 4 inches
5 foot 5 inches
5 foot 6 inches
5 foot 7 inches
5 foot 8 inches
5 foot 9 inches
5 foot 10 inches
5 foot 11 inches
6 foot
6 foot 1 inch
6 foot 2 inches
6 foot 3 inches
6 foot 4 inches
6 foot 5 inches
6 foot 6 inches
6 foot 7 inches
6 foot 8 inches
6 foot 9 inches
6 foot 10 inches
6 foot 11 inches
7 foot
7 foot 1 inch
7 foot 2 inches
7 foot 3 inches
7 foot 4 inches
7 foot 5 inches
7 foot 6 inches
7 foot 7 inches
Comment
*
weight in pounds before
*
Weight Comments
*
About currently under weight
*
Amount currently over weight
*
rate you overall state of health at entry / today in a scale of 1-5 five being the best
*
1
2
3
4
5
Family medical history
*
heart disease
Asthma
Migraines
liver disease
kidney disease
`Prostate issues
Diabetes
Cancer
Allergies
Hi blood pressure
other pease comment ______
other family issues
*
Current medical history
*
Night sweats
Chills
blood in stool
Severe headaches
Diarrhea
Constipation
Passed out
Vision loss
Dizzynes
Hearing loss
Pressure in eyes
Problems with knight vision
Heart burn
Stomach ulcers
Anxiety
burning during urination
Depressed
Irritable
Blood in urine
Allergies
Congested sinuses
Thyroid problems
Cough
COPD
STD
Herpes 1 cold sore
Herpes 2 SDT
Herpes 3 Chicken pocks
Herpes 4 Epsteins barr
Herpes 6
Herpes 7
Herpes 8
AIDS
fluid on the lungs
Diabetes
Hi blood pressure
jaundice
hepatitus A
Hepatitis B
Hepatitis C
Gout
Skin Rashes
Skin dark spots
skin tags / moles
Varicose veins
fatigued
skin crawl or itch
Swollen glands
fever
Chest pain
Fatigued even when rested
other personal medical issues
*
WOMEN
*
ARE YOU PREGNANT
Do you have children
Are your children healthy
Are your mensural periods generally on time
do you have excessive pain during mensturation
blood clots during mensuration
excessive flow
pain in overies
hysterectomy
lumps in breast
Lumps under arm
lumps in groin area
lumps in stomach area
lumps in fatty tissue
Are you on birth control
Men
*
lump in the groin
lumps in the stomach
lumps in fatty tissue
lumps under arms
Reduced ejacualtion force
Reduced Erection
Enlarged prostate
regarding urine flow, on a scale of 1-5 rate your level of improvement 5 being the best
*
1
2
4
5
Urin flow Comments
*
Regarding actual PSA improvement on a scale of 1-5 Rate you level of improvent 5 being the best
*
1
2
3
4
5
PSA comments (please include dates if possible)
*
Regarding sexual performance on a scale of 1-5 Rate you level of improvent 5 being the best
*
1
2
3
4
5
Sexual performance Comments
*
Regarding overall quality of life on a scale of 1-5 Rate you level of improvent 5 being the best
*
1
2
3
4
5
Overall quality of life Comments
*
Regarding skin tone and elasticity on a scale of 1-5 Rate you level of improvent 5 being the best
*
1
2
3
4
5
Skin Comment
*
Age spot and skin tag reduction on a scale of 1-5 Rate you level of improvent 5 being the best
*
1
2
3
4
5
Grey hair reduction on a scale of 1-5 Rate you level of improvent 5 being the best
*
1
2
3
4
5
Hair health and texture reduced split ends on a scale of 1-5 Rate you level of improvent 5 being the best
*
1
2
3
4
5
Hair Regrowth on a scale of 1-5 Rate you level of improvent 5 being the best
*
1
2
3
4
5
Hair Comments
*
FLEXIBILITY ON A SCALE OF 1-5 RATE YOU LEVEL OF IMPROVENT 5 BEING THE BEST
*
1
2
3
4
5
physique comments
*
MUSCLE MASS ON A SCALE OF 1-5 RATE YOU LEVEL OF IMPROVENT 5 BEING THE BEST
*
1
2
3
4
5
ENDURANCE ON A SCALE OF 1-5 RATE YOU LEVEL OF IMPROVENT 5 BEING THE BEST
*
1
2
Option 3
STRENGTH ON A SCALE OF 1-5 RATE YOU LEVEL OF IMPROVENT 5 BEING THE BEST *
*
1
2
3
4
5
lead investigator
*
First
Last
lead investigator Address
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Line 1
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City
State
Zip Code
Country
Lead investigator Phone Number
*
Investigator assistant
*
First
Last
[object Object]
Email
*
investigator assistant address
*
Line 1
Line 2
City
State
Zip Code
Country
`investigator assistant phone #
*
review board chair
*
First
Last
[object Object]
Chairman's address
*
Line 1
Line 2
City
State
Zip Code
Country
chairman's email
*
Chairman's chair email
*
#1 Review Board member
*
First
Last
[object Object]
#1 Review board member address
*
Line 1
Line 2
City
State
Zip Code
Country
#1 review board member Phone Number
*
#2 Review board member
*
First
Last
[object Object]
#2 review board member Address
*
Line 1
Line 2
City
State
Zip Code
Country
#2 review board member Phone Number
*
#2 review board member email
*
Internal review board institution
*
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City
State
Zip Code
Country
Instution contact person
*
First
Last
Institution contact phone number
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institution contact email
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Your Name will be kept confidential and separate from published results by checking below you do provide Flawless herbs the right to publish the results of this study.
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no
Submit
Possible side effects as per Web MD regarding Tripterygium Wilfordiii
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