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Thank you for visiting the Vista Medical Research website. We at Vista are committed to protecting your privacy. We will not share the information you give us with anyone. We do not collect or sell information for commercial purposes. The information you provide will be used strictly for the purpose of evaluating your eligibility into one of our research studies.

If you have any questions, or would feel more comfortable submitting your application in person, please feel free make a screening appointment with us at (480) 641-2128.

Contact Information
Your Name:
E-mail Address:
Your Phone number?
Date of Birth:
Sex:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Are you a full time resident? Yes
   

Medical Information
Please check the box if any of the following apply to you:
Alcohol
Consumption/Frequency?
Coffee/Caffeine
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Tobacco/Smoking
Consumption/Frequency?
Contacts
Glasses
Please list any medications you are currently taking:
List any known allergies to medications:
   

Medical History
Please check the appropriate box if you are currently experiencing any of the following or have experienced within the past 12 months.
Abnormal EKG
Alcohol/Substance Abuse
Anemia
Angina
Arthritis/Osteo
Arthritis/Rheumatoid
Asthma
Back Pain/Problems
Blurred Vision
Bronchitis
Cancer/Female Specific
Cancer/Colon
Cancer/Lung
Cancer/Male
Cancer/Pancreatic
Cancer/Other
Carotid Arteries
Cataracts
Crohn's Disease
Chronic Fatigue
Chronic Lung Disease
Chronic Obstructive Pulmonary Disease
Chronic Pain
Cirrhosis of the Liver
Congestive Heart Failure
Deafness
Diabetes/Insulin Dependent
Diabetes/Type II
Diabetes/Diet Controlled
Diverticulitis
Emphysema
Epilepsy
Excema
Fibromyalgia
GERD
Gall Stones
Glaucoma
Goiter
Gout
Hay Fever/Seasonal Allergies
Heart Attack
Heart Murmur
Heart Problems
Heartburn/Indigestion
Hemorroids
Hepatitis
Hernia
Hiatal Hernia
High Blood Pressure
High Cholesterol
Impotence
Incontinence
Insomnia
Irritable Bowel Syndrome
Kidney Disorder/Stones
Lymphoma
Memory Loss
Migraines
Neuropathy
Obesity
Osteoporisis
Polio
Prostate
Psychiatric Disorder
Rheumatic Fever
Skin Yeast Infections
Sleep Apnea
Stroke
TMJ
Thyroid (Overactive)
Thyroid (Underactive)
Ulcer
Ulcerative Colitis
Varicose Veins
   
Any additional comments or questions?