Name:
First: M.I: Last:

Address:
Street:

City: State: Zip:

Phone and Email:
Home Phone: ( ) -

Work Phone: ( ) -

Permanent Phone: ( ) -

Email:

If you work, what shift are you on? Days Evenings Nights Not Applicable
(Some studies exclude people who work certain shifts.)

Percent time: Part Time Full Time Not Applicable

Is it okay to call you at work? Yes No Not Applicable

Birthday: / / (mm/dd/yyyy)
(Age is an important critera for many studies.)

Gender: Male Female

Race or ethnicity:
African American Asian Caucasian Hispanic
Native American Other I wish not to disclose

Have you ever been diagnosed with asthma?
Yes No No (but I have symptoms)

Have you ever been diagnosed with allergies?
Yes No No (but I have symptoms)

Do you have any history of smoking?
Current Past Never
If current or past, what year did you start? (yyyy)
If past, what year did you stop? (yyyy)
If applicable, what was the average number of cigarettes that you smoked per day?

Please add any additional comments or information here: