Horizons Clinical Research Center, LLC
Questionnaire
© Copyright 2007 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 acne.
How did you learn about us?
Are you at least 12 years of age? (if under the age of 18 parental consent is
necessary to participate.)
 Yes
 No
Are you pregnant, lactating, or plan to be pregnant within the next 3 months?
 Yes
 No
Do you have a beard, facial tattoos, or excessive facial scarring?
 Yes
 No
Do you have any other facial skin condition in addition to the acne?
 Yes
 No
Do you have an allergy or sensitivity to any medications?
 Yes
 No
Are you currently receiving any treatment for your acne?
 Yes
 No
What is your approximate weight?
What is your approximate height?
Your name:
Your e-mail address:
Your phone number:
Comments:
You need Java to see this applet.
sitemap