Health Research Study Participant Application

First name *

Last Name *

Age *

Gender *

Male

Female

Address *

City *

Province

Postal code *

Email *

Telephone *

Family Doctor *

Emergency contact *

Emergency telephone *

Do you have a family history of:

Other

All information is confidential and used exclusively for the purposes of Gateway research. No information from this application will be shared with third parties.

Tel. 519.600.2273 xt 246

	Yes	No
Stroke
Diabetes
High Blood Pressure
High Cholesterol
COPD
Asthma
Cancer

	Yes	No
Smoking
Exercise regularly
Alcohol intake
Sleeping problems
Weight problems

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Health Research Study Participant Application