Phase I Clinical Trial Screening Form
Participant Information
Full Name
Date of Birth
Gender
Male
Female
Other
Contact Number
Email Address
Medical History
Relevant Medical History
Current Medical Conditions
Current Medications
Eligibility Criteria
Known Allergies
Smoking Status
Non-Smoker
Ex-Smoker
Current Smoker
Alcohol Use
None
Occasional
Regular
Previous Clinical Trial Participation
Yes
No
Comments/Notes