Intake Form

The mission of Tandem Clinical Research is to advance the science of medicine while improving the quality of life of our patients. Our medical team believes in providing exemplary care to our patients while conducting research with compassion and respect to our study participants. We offer our services to the greater New Orleans area.

We provide a friendly environment where patients have the opportunity to help shape the future of health for themselves, loved-ones and others.

Official Intake Form

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DEMOGRAPHIC INFORMATION

PATIENT CONTACT INFORMATION

EMERGENCY CONTACT

PRIMARY CARE PHYSICIAN INFORMATION

TOBACCO HISTORY

ALCOHOL HISTORY

ALLERGIES

FAMILY HISTORY

Name of Person & Relation to You

REVIEW OF BODY SYSTEMS

Please indicate if you have any of the following:

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MALES - METHOD OF CONTRACEPTION

FEMALES - REPRODUCTIVE HISTORY

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SURGICAL HISTORY

ANY OTHER MEDICAL CONDITIONS

PRESCRIPTION MEDICATIONS

OVER THE COUNTER MEDICATIONS

Patient Signature

CRC/Investigator Signature

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