Current status Update Form

Screening Visit

Submitted by Lab on Thu, 03/07/2013 - 16:08

(to be completed at time of collection) Use 0=NO, 1=YES

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What time is it right now?
Have you eaten today
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Have you taken any asthma medication in the last 24 hours?
Have you taken any allergy medication in the last 24 hours?
Have you taken any other medication (even over the counter medication) in the last 24 hours?
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WOMEN ONLY:
Yesterday did you experience any of the following? Use 0=NO, 1=YES