Rare Disease Study Recruitment Questionnaire
Personal Information
Full Name
Date of Birth
Email
Phone Number
Location (City, Country)
Medical History
Have you been diagnosed with a rare disease?
Yes
No
If yes, what is the name of the disease?
Diagnosis Date
Are you currently receiving treatment?
Yes
No
Current or Recent Treatments
Eligibility Information
Have you participated in a clinical study before?
Yes
No
Are you willing to be contacted for future studies?
Yes
No
Comments or Additional Information