Registration Form

Personal Details

(as shown on identification document e.g. Driver’s Licence, Passport)

Title: *


Given Names: *
Last Name: *
Date of Birth: *
Open the calendar popup.
 
Gender: *
Ethnicity:
Height (centimetres):
 
Weight (kilograms):
 
Body Mass Index (BMI):

Contact Details

Street Address: *
Suburb: *
City: *
Post Code:
Home Phone: *
Mobile Phone:
Work Phone:
Email: *

Family Doctor

Doctor's Name:
Doctor's Address:
Doctor's Phone:
Doctor's Fax:

Employment Status

Are you? (please select): *


Relevant History

Smoking History
Smoking history: *

Year Last Smoked:
Cigarettes per day:

Medical History
List all known allergies (including drug and food allergies):
List any known medical contitions:
(e.g. diabetes, cancer, migraine, asthma, high blood pressure etc.)

List any medications that you take regularly (including herbal remedies, supplements or any contraceptive therapy)
Drug name:
Conditions Used For:

Have you ever had any of the following? (Please indicate and include year of procedure)
Hysterectomy (indicate year if relevant)
Tubal Ligation (indicate year if relevant)
Vasectomy (indicate year if relevant)

If you have ever participated in a clinical trial before please indicate the year below:
Year Of Prev Trial:
Where was your previous trial? (if relevant):

Additional Information

How did you hear about us?:


If other, please explain:

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I consent to ACS holding the information given above on a database and understand this information will remain confidential and only be used by ACS.  

Version 2, 24 March 2010