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Medical Questionnaire

Thank you for applying to become a patient at Synexus. It is important that we have an accurate record of your medical history and we would appreciate you spending a few minutes to click on the boxes below, if you suffer from or have suffered from any of the conditions listed. We will then attempt to match studies that may be of interest to you and only contact you when necessary.

Your Details

The following sections detail various medical conditions. Please tick any of the conditions that you suffer from.

Cardiovascular
Gastrointestinal
Respiratory Disease
Skin
Musculoskeletal
Arthritis
Fracture (a broken bone)
Central Nervous System
Metabolism
Type I Diabetes
Type II Diabetes
Height and weight

To enter your height and weight in meters and kilograms,select Metric. If your height is 1.2m and weight is 67.5kg, for height enter 1 in first height box and 2 in second height box. For weight enter 67 in first weight box and 5 in second weight box.

To enter your height and weight in stones and height in feet, select Imperial. If your height is 5ft 8inches and weight 10 stones 6 lbs, for height enter 5 in the first height box and 8 in the second height box. For weight enter 10 in first weight box and 6 in second weight box.

Imperial Metric
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Immunological
Psychiatry
Cancer
Genitourinary
Female
Male
Lifestyle
Sexual disorder
Females
Male
Any other conditions not mentioned?
Data Protection Act
Privacy Policy
Contact Method

Email alerts

If you are interested in receiving information about Synexus, please let us have your email address and we will send you up to date details.

Have more questions?

If you have any questions about a specific study, please contact the Synexus clinic that you are attending and speak to your doctor there.

General questions?

Contact us

Synexus Limited, Registered in England and Wales, Registered number 3724238, Registered Office: Sandringham House, Ackhurst Park, Chorley , Lancashire, PR7 1NY