Horizons Clinical Research Center, LLC
Questionnaire
© Copyright 2007-2011 Horizons Clinical Research Center, LLC / All Rights Reserved

    Questionnaire for potential patients interested in participating in the research study for the
    treatment of moderate to severe facial acne.
How did you learn about us?
Are you at least 12 years of age but not more than 45? (if under the age of 18
parental consent is necessary to participate.)
 Yes
 No
Yes
 No
Are you pregnant, breastfeeding, or plan to be pregnant within the next 4 months?
Do you have at least 20 inflamed pimples and at least 20 blackheads and/or
whiteheads on your face?
 Yes
 No
Do you have any other serious skin condition in addition to acne?
 Yes
 No
Do you have a beard?
 Yes
 No
Have you participated in any other research studies within the past 30 daus?
 Yes
 No
Your name:
Your e-mail address:
Your phone number:
Comments:
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