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 a research study for the treatment of High Blood
    Pressure in those with Type 2 Diabetes.
How did you learn about us?
Are you at least 18 years of age?
 Yes
 No
Are you pregnant, or breastfeeding?
 Yes
 No
Have you been diagnosed with Stage 2 systolic hypertension?
 Yes
 No
Have you been diagnosed with type II diabetes?
 Yes
 No
Are you required to take insulin?
 Yes
 No
Would you like us to contact you for future hypertension and/or diabetes studies?
 Yes
 No
Your name:
Your e-mail address:
Your phone number:
Comments:
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