For what diagnosis or problem are you seeking treatment?
What is your age?
male female
How did you hear about Carman Research? (choose all that apply)
TV
Print
Website
Direct Mail
E-Newsletter
Other
Please Describe:
Can you come for weekly outpatient visits at our Smyrna office for at least six (6) weeks?
yes no
How long have you been feeling the way you feel today?
Please describe your symptoms (both physical and emotional).
Have you ever had a seizure?
How many?
Age at time of last seizure?
Do you have an unstable medical illness? yes no
Have you ever had, or do you currently have a form of cancer? yes no
Type of cancer:
Date of last treatment:
Type of treatment:
Chemo
Radiation
Surgery
What medication(s) or herb(s) are you currently taking?
What antidepressants are you currently taking?
Do you have any Allergies? yes no
Please list medicines that you are allergic to:
Please list any other allergies:
Have you ever been treated for alcoholism?
Dates of treatment:
When was your last use of alcohol?
Have you ever been treated for drug dependency?
When was your last use of any street drug? (e.g., Marijuana, Cocaine, Methamphetamines, etc.)
Contact Information * fields are required
First Name: *
Last Name: *
Home Phone Number:
Office Phone Number:
Cell Phone Number:
E-mail Address: *
Best method to contact you (choose 2):
home #
office #
cell #
E-mail
Best time to contact you:
Other Information you would like to share:
PLEASE NOTE: IN ORDER TO PARTCIPATE IN A CLINICAL STUDY, ALL ELIGIBLE PARTICIPANTS WILL HAVE TO PASS A DRUG SCREEN FOR DRUGS OF ABUSE.