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aSBo Online Registration
Let's get started to see if you qualify for a clinical study!
Let's get started to see if you qualify for a clinical study.
Please note that at this moment subject recruitment is limited to volunteers that are based in the Kanto region of Japan.
OK
1.
How did you hear about this volunteer association?
If referred by a friend please
Enter name:
If by internet/social media
i.e. Craigslist etc, please indicate:
*
2.
Please provide your personal information
(Required.)
Surname
Middle name
First name
Post code
Prefecture
City
Town
*
3.
What is your gender?
(Required.)
Female
Male
4.
If you are female, please select one of the categories below;
I am of childbearing potential
I can't bear children, please specify reason e.g Post-menopausal, surgically sterile etc. below;
*
5.
What is your date of birth? Please state in (MM/DD/YYYY).
(Required.)
*
6.
What is your height & weight? Please state in cm and kg.
(Required.)
Height:
Weight:
*
7.
What is your nationality?
(Required.)
*
8.
What is your Ethnicity/Race?
(Required.)
Chinese
Taiwanese
Korean
Indian
Black or African heritage
White
Hispanic
Other (please specify)
*
9.
Do you have any history of asthma or serious disease. Please state:
(Required.)
*
10.
If you drink alcohol please state approximately how much you drink in a week, if not please enter zero?
(Required.)
*
11.
Do you smoke?
(Required.)
Yes
No
*
12.
What kind of Visa do you have now?
(Required.)
*
13.
What is your Email address?
(Required.)
*
14.
What is your Mobile Number?
(Required.)
