Intake Form | Tandem Clinical Research

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

*Fields with asterisks are required.

DEMOGRAPHIC INFORMATION

First & Last Name*Date of Completion*
‍(mm/dd/yyyy)Date of Birth*
‍(mm/dd/yyyy)Age*Sex*Race*Marital StatusHighest Level of Education*Occupation

PATIENT CONTACT INFORMATION

Street Address*City, State, Zip*Country*Home PhoneCell PhoneEmailWhen is the best time of day to contact you?

EMERGENCY CONTACT

Primary Emergency Contact FIrst & Last NamePrimary Contact PhoneSecondary Emergency Contact First & Last NameSecondary Contact Phone

PRIMARY CARE PHYSICIAN INFORMATION

Primary Care Physician or Office Name*Street Address*City, State, Zip*Country*Office NumberFax NumberWere you referred by a physician?

TOBACCO HISTORY

Have you ever smoked tobacco products?*

ALCOHOL HISTORY

Have you ever consumed alcohol?*

ALLERGIES

NoneFood/Drug AllergyStart Date
‍(mm/dd/yyyy)Reaction

FAMILY HISTORY

Name of Person & Relation to You

Heart Disease/Heart AttackDiabetes Type I or IIAsthmaDementia

REVIEW OF BODY SYSTEMS

Please indicate if you have any of the following:

EyesStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

Ear, Nose & ThroatStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

CardiovascularStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

GastrointestinalStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

Endocrine/MetabolicStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

HematologicStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

ImmunologicStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

HepaticStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

RenalStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

Urogenital/GynecologicStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

MALES - METHOD OF CONTRACEPTION

N/A: I am FemaleVasectomySterile PartnerCondoms/SpermicideAbstinenceOtherNone

FEMALES - REPRODUCTIVE HISTORY

N/A: I am MaleAre you currently pregnant, lactating, or breast feeding?Number of PregnanciesNumber of Live BirthsNumber of C-SectionsSpecify Birth DatesCheck all reproductive procedures you have received:Bilateral Tubal LigationComplete HysterectomyUterine AblationContraceptive Implant PlacementPartial HysterectomyBilateral OophorectomyIUD PlacementWhen was your last menstrual period?
‍(mm/dd/yyyy)If you are no longer having menstrual periods, was this spontaneous or due to a procedure?Current Method of ContraceptionSurgically SterileTransdermal Patch ContraceptiveCondoms/SpermicidePostmenopausalIUDAbstinenceOral ContraceptivesContraceptive ImplantSterile PartnerOtherNone

MusculoskeletalStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

PsychiatricStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

NeurologicStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

SkinStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)OngoingAdditional Items?

Please list items and the respective start/stop dates.

SURGICAL HISTORY

SurgeryDate
‍(mm/dd/yyyy)Reason for SurgeryDo you anticipate or expect surgery in the next year?

ANY OTHER MEDICAL CONDITIONS

DiagnosisStart Date
‍(mm/dd/yyyy)Stop Date
‍(mm/dd/yyyy)Ongoing

PRESCRIPTION MEDICATIONS

MedicationCurrent DoseHow Often?Start Date
‍(mm/dd/yyyy)Taken for What?

OVER THE COUNTER MEDICATIONS

MedicationCurrent DoseHow Often?Start Date
‍(mm/dd/yyyy)Taken for What?

Patient Signature

Please type in your full nameDate
‍(mm/dd/yyyy)

CRC/Investigator Signature

Please type in your Full NameDate
‍(mm/dd/yyyy)

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