Selecting volunteers -Antibiotice

FULL NAME

ADDRESS

PHONE NO.

EMAIL

PROFESSION

GENDER

AGE

HEIGHT [cm]

WEIGHT [kg]

MEDICAL RECORD

DO YOU HAVE ANY KNOWN AlLERGIES?*
DANU

If the answer is "Yes", specify which type (1. food; 2 medicinal products; 3. other):

HAVE YOU HAD ANY SURGERIES?
DANU

If the answer is "Yes", specify the diagnostic:

DISEASES
DANU

If the answer is "Yes", specify the diagnostic:

TREATMENTS / MEDICATION
Please specify if you are taking or have taken any medication or treatment usually / often:
DANU

If the answer is "Yes", specify the drug.

If the answer is "Yes", specify when and for long you have taken the respective drug.

Lifestyle
What type of diet do you have? (1.mixted; 2.lacto-vegetarian, 3. ovo-lacto-vegetarian)?

Do you usually exclude any food from your daily diet?
DANU

If the answer is "Yes", specify which.

Do you drink coffee regularly?
DANU

If the answer is YES, specify how often ( 1.daily. 2. Weekly. 3. Occasionally)

Do you smoke?
DANU

If the answer is yes, specify how frequently (1.under 10 cigarettes / day, 2. Over 10 cigarettes/day; 3. Occasionally)

Do you drink any alcohol?
DANU

If the answer is yes, specify how often (1. daily. 2 weekly. 3. occasionally)

Are you a blood donor?
DANU

If the answer is "Yes", state the date of your last donation:

Have you ever participated in a clinical trial?
DANU

If so, specify the date of the last trial: