Elligo Patient Registry

"*" indicates required fields

1Contact Information

2Patient Information

3Medical History

4Surgical History

5Medications and Immunizations

1. Contact Information

First Name*

Last Name*

Address*

Example: 123 Main St.

Apartment, Suite, etc.

Example: Apt. 2B

City*

State*

Zip Code*

Email*

Phone*

Phone Type

Mobile

Home

Primary Language

Other Primary Language

How did you hear about this opportunity?

Other

I have read and agree to the Privacy Policy and agree to be contacted if I potentially qualify for a clinical trial.*

SMS Consent

I agree to receive automated SMS messages from Elligo, and/or its affiliates, service providers, or vendors to the mobile phone number provided above regarding eligibility to participate in clinical trials. Message and data rates may apply.

2. Patient Information

Date of Birth*

Month

Day

Year

Sex (assigned at birth)*

Pronouns

Height

Feet

Height (inches)

Inches

Weight

Pounds

What is your race?

Select one or more

White

Black or African American

American Indian or Alaska Native

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Are you Hispanic, Latino/a, or of Spanish origin?

No - not of Hispanic, Latino/a, or Spanish origin

Yes - select one or more Hispanic, Latino/a, Spanish origin:

Hispanic, Latino/a, Spanish Origin Options*

Mexican, Mexican American, Chicano/a

Puerto Rican

Cuban

Other Hispanic, Latino/a, Spanish origin

3. Medical History

Do you currently have or have a history of any of the following conditions?

Check the box to the left of each condition you’ve experienced, and add a comment in the box on the right with the dates you experienced the condition and any related information. For example, indicating the location of a skin condition.

Dermatology

Psoriasis

Psoriasis - options

Ongoing

Prior History

Psoriasis Comments

Add dates of psoriasis occurrence and any related comments

Eczema

Eczema - options

Ongoing

Prior History

Eczema Comments

Add dates of eczema occurrence, location, and any related comments

Basal Cell Cancer

Basal Cell Cancer - options

Ongoing

Prior History

Basal Cell Cancer Comments

Add dates of basal cell cancer occurrence and any related comments

Squamous Cell Cancer

Squamous Cell Cancer - options

Ongoing

Prior History

Squamous Cell Cancer Comments

Add dates of squamous cell cancer occurrence and any related comments

Other Dermatology History

Other Dermatology History - options

Ongoing

Prior History

Other Dermatology History Comments

Add dates of other dermatology history and any related comments

Pulmonology / Respiratory

COPD / Emphysema

COPD / Emphysema - options

Ongoing

Prior History

COPD / Emphysema Comments

Add dates of COPD / emphysema occurrence and any related comments

Bronchiectasis

Bronchiectasis - options

Ongoing

Prior History

Bronchiectasis Comments

Add dates of bronchiectasis occurrence and any related comments

Asthma

Asthma - options

Ongoing

Prior History

Asthma Comments

Add dates of asthma occurrence and any related comments

Obstructive Sleep Apnea

Obstructive Sleep Apnea - options

Ongoing

Prior History

Obstructive Sleep Apnea Comments

Add dates of obstructive sleep apnea occurrence and any related comments

Other Respiratory History

Other Respiratory History - options

Ongoing

Prior History

Other Respiratory History Comments

Add dates of other respiratory history and any related comments

Cardiology / Vascular Diseases

Coronary Artery Disease

Coronary Artery Disease - options

Ongoing

Prior History

Coronary Artery Disease Comments

Add dates of coronary artery disease occurrence and any related comments

Angina

Angina - options

Ongoing

Prior History

Angina Comments

Add dates of angina occurrence and any related comments

Heart Attack

Heart Attack - options

Ongoing

Prior History

Heart Attack Comments

Add dates of heart attack occurrence and any related comments

Congenital Heart Disease

Congenital Heart Disease - options

Ongoing

Prior History

Congenital Heart Disease Comments

Add dates of congenital heart disease occurrence and any related comments

Heart Murmur

Heart Murmur - options

Ongoing

Prior History

Heart Murmur Comments

Add dates of heart murmur occurrence and any related comments

Heart Valve Abnormality

Heart Valve Abnormality - options

Ongoing

Prior History

Heart Valve Abnormality Comments

Add dates of heart valve abnormality occurrence and any related comments

High Cholesterol

High Cholesterol - options

Ongoing

Prior History

High Cholesterol Comments

Add dates of high cholesterol occurrence and any related comments

High Triglycerides

High Triglycerides - options

Ongoing

Prior History

High Triglycerides Comments

Add dates of high triglycerides occurrence and any related comments

High Blood Pressure

High Blood Pressure - options

Ongoing

Prior History

High Blood Pressure Comments

Add dates of high blood pressure occurrence and any related comments

Blood Clots (DVT/PE)

Blood Clots (DVT/PE) - options

Ongoing

Prior History

Blood Clots (DVT/PE) Comments

Add dates of blood clots (DVT/PE) occurrence, where (e.g. leg, lung, etc.) and any related comments

Circulation Problems (PAD, PVD)

Circulation Problems (PAD, PVD) - options

Ongoing

Prior History

Circulation Problems (PAD, PVD) Comments

Add dates of circulation problems (PAD, PVD) occurrence, where (which limb), and any related comments

Arrhythmia

Arrhythmia - options

Ongoing

Prior History

Arrhythmia Comments

Add dates of arrhythmia and any related comments

Other Cardiovascular History

Other Cardiovascular History - options

Ongoing

Prior History

Other Cardiovascular History Comments

Add dates of other cardiovascular history and any related comments

Gastroenterology / Hepatology

Gastroesophageal Reflux (GERD)

Gastroesophageal Reflux (GERD) - options

Ongoing

Prior History

Gastroesophageal Reflux (GERD) Comments

Add dates of gastroesophageal reflux (GERD) occurrence and any related comments

Gallbladder Disease

Gallbladder Disease - options

Ongoing

Prior History

Gallbladder Disease Comments

Add dates of gallbladder disease occurrence and any related comments

Hepatitis

Hepatitis - options

Ongoing

Prior History

Hepatitis Comments

Add dates of hepatitis occurrence, type (e.g. A, B, C, D, or E), and any related comments

Diverticulosis/itis

Diverticulosis/itis - options

Ongoing

Prior History

Diverticulosis/itis Comments

Add dates of diverticulosis/itis occurrence and any related comments

Irritable Bowel Syndrome

Irritable Bowel Syndrome - options

Ongoing

Prior History

Irritable Bowel Syndrome Comments

Add dates of irritable bowel syndrome occurrence and any related comments

Inflammatory Bowel Disease

Inflammatory Bowel Disease - options

Ongoing

Prior History

Inflammatory Bowel Disease Comments

Add dates of inflammatory bowel disease occurrence, type (e.g. Crohn's, UC, etc.), and any related comments

Liver Disease

Liver Disease - options

Ongoing

Prior History

Liver Disease Comments

Add dates of liver disease occurrence, type (e.g. NASH, NAFLD, etc.), and any related comments

Other Gastroenterology History

Other Gastroenterology History - options

Ongoing

Prior History

Other Gastroenterology History Comments

Add dates of other gastroenterology history and any related comments

Urology

Enlarged Prostate

Enlarged Prostate - options

Ongoing

Prior History

Enlarged Prostate Comments

Add dates of enlarged prostate occurrence and any related comments

Incontinence

Incontinence - options

Ongoing

Prior History

Incontinence Comments

Add dates of incontinence occurrence and any related comments

Kidney Disease

Kidney Disease - options

Ongoing

Prior History

Kidney Disease Comments

Add dates of kidney disease occurrence and any related comments

Frequent Urinary Tract Infection (UTI)

Frequent Urinary Tract Infection (UTI) - options

Ongoing

Prior History

Frequent Urinary Tract Infection (UTI) Comments

Add dates of urinary tract infection (UTI) occurrence and any related comments

Other Urologic History

Other Urologic History - options

Ongoing

Prior History

Other Urologic History Comments

Add dates of other urologic history and any related comments

Gynecology / Obstetrics

Uterine Fibroids

Uterine Fibroids - options

Ongoing

Prior History

Uterine Fibroids Comments

Add dates of uterine fibroids occurrence and any related comments

Endometriosis

Endometriosis - options

Ongoing

Prior History

Endometriosis Comments

Add dates of endometriosis occurrence and any related comments

Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome - options

Ongoing

Prior History

Polycystic Ovarian Syndrome Comments

Add dates of polycystic ovarian syndrome occurrence and any related comments

Other Gynecologic History

Other Gynecologic History - options

Ongoing

Prior History

Other Gynecologic History Comments

Add dates of other gynecologic history and any related comments

Endocrinology

Diabetes Type 1

Diabetes Type 1 - options

Ongoing

Prior History

Diabetes Type 1 Comments

Add dates of Diabetes Type 1 occurrence and any related comments

Diabetes Type 2

Diabetes Type 2 - options

Ongoing

Prior History

Diabetes Type 2 Comments

Add dates of Diabetes Type 2 occurrence and any related comments

Thyroid Disease

Thyroid Disease - options

Ongoing

Prior History

Thyroid Disease Comments

Add dates of thyroid disease occurrence, type (e.g. hypo/hyper, goiter, etc.), and any related comments

Parathyroid Disease

Parathyroid Disease - options

Ongoing

Prior History

Parathyroid Disease Comments

Add dates of parathyroid disease occurrence and any related comments

Adrenal Disease

Adrenal Disease - options

Ongoing

Prior History

Adrenal Disease Comments

Add dates of adrenal disease occurrence and any related comments

Low Testosterone

Low Testosterone - options

Ongoing

Prior History

Low Testosterone Comments

Add dates of low testosterone and any related comments

Other Endocrine History

Other Endocrine History - options

Ongoing

Prior History

Other Endocrine History Comments

Add dates of other endocrine history and any related comments

Neurology / Psychiatry / Pyschology

Headaches

Headaches - options

Ongoing

Prior History

Headaches Comments

Add dates of headaches occurrence and any related comments

Epilepsy/Seizures

Epilepsy/Seizures - options

Ongoing

Prior History

Epilepsy/Seizures Comments

Add dates of epilepsy/seizures occurrence and any related comments

Stroke

Stroke - options

Ongoing

Prior History

Stroke Comments

Add dates of stroke occurrence, residual symptoms, and any related comments

Parkinson’s Disease

Parkinson’s Disease - options

Ongoing

Prior History

Parkinson’s Disease Comments

Add dates of Parkinson’s disease occurrence and any related comments

Dementia

Dementia - options

Ongoing

Prior History

Dementia Comments

Add dates of dementia occurrence, type of dementia, and any related comments

Multiple Sclerosis

Multiple Sclerosis - options

Ongoing

Prior History

Multiple Sclerosis Comments

Add dates of Multiple Sclerosis occurrence and any related comments

Narcolepsy

Narcolepsy - options

Ongoing

Prior History

Narcolepsy Comments

Add dates of narcolepsy occurrence and any related comments

Insomnia

Insomnia - options

Ongoing

Prior History

Insomnia Comments

Add dates of insomnia occurrence and any related comments

Depression

Depression - options

Ongoing

Prior History

Depression Comments

Add dates of depression occurrence and any related comments

Schizophrenia

Schizophrenia - options

Ongoing

Prior History

Schizophrenia Comments

Add dates of schizophrenia occurrence and any related comments

Migraines

Migraines - options

Ongoing

Prior History

Migraines Comments

Add dates of migraines occurrence and any related comments

Anxiety

Anxiety - options

Ongoing

Prior History

Anxiety Comments

Add dates of anxiety and any related comments

Other Neurologic or Psychiatric History

Other Neurologic or Psychiatric History - options

Ongoing

Prior History

Other Neurologic or Psychiatric History Comments

Add dates of other neurologic or psychiatric history and any related comments

Orthopedics / Rheumatology

Fractures

Fractures - options

Ongoing

Prior History

Fractures Comments

Add dates of fractures occurrence, where (which bones), and any related comments

Osteoporosis

Osteoporosis - options

Ongoing

Prior History

Osteoporosis Comments

Add dates of osteoporosis occurrence and any related comments

Osteoarthritis

Osteoarthritis - options

Ongoing

Prior History

Osteoarthritis Comments

Add dates of osteoarthritis and any related comments

Rheumatoid Arthritis

Rheumatoid Arthritis - options

Ongoing

Prior History

Rheumatoid Arthritis Comments

Add dates of rheumatoid arthritis and any related comments

Gout

Gout - options

Ongoing

Prior History

Gout Comments

Add dates of gout and any related comments

Other Orthopedic History

Other Orthopedic History - options

Ongoing

Prior History

Other Orthopedic History Comments

Add dates of other orthopedic history and any related comments

Infections / Parasitic Diseases

HIV/AIDS

HIV/AIDS - options

Ongoing

Prior History

HIV/AIDS Comments

Add dates of HIV/AIDS occurrence and any related comments

Tuberculosis

Tuberculosis - options

Ongoing

Prior History

Tuberculosis Comments

Add dates of Tuberculosis occurrence and any related comments

Recurrent Infections of Any Kind

Recurrent Infections of Any Kind - options

Ongoing

Prior History

Recurrent Infections of Any Kind Comments

Add dates of recurrent infection occurrences, type of infection (e.g. skin, eye, sinus, etc.) and any related comments

Shingles

Shingles - options

Ongoing

Prior History

Shingles Comments

Add dates of shingles occurrence and any related comments

Other Infection History

Other Infection History - options

Ongoing

Prior History

Other Infection History Comments

Add dates of other infection history and any related comments

Allergy / Immunology

Immune Deficiency Disorder

Immune Deficiency Disorder - options

Ongoing

Prior History

Immune Deficiency Disorder Comments

Add dates of immune deficiency disorder occurrence, type (e.g. CVID, SCID, etc.), and any related comments

Chronic Allergies

Chronic Allergies - options

Ongoing

Prior History

Chronic Allergies Comments

Add dates of chronic allergies occurrence and any related comments

Autoimmune Disorders

Autoimmune Disorders - options

Ongoing

Prior History

Autoimmune Disorders Comments

Add dates of autoimmune disorders occurrence, type (e.g. Lupus, Rheumatoid Arthritis), and any related comments

Other Immunology History

Other Immunology History - options

Ongoing

Prior History

Other Immunology History Comments

Add dates of other immunology history and any related comments

Hematology / Oncology

Cancer

Cancer - options

Ongoing

Prior History

Cancer Comments

Add date(s) and type(s) of cancer(s) and any related comments

Anemia

Anemia - options

Ongoing

Prior History

Anemia Comments

Add dates of anemia and any related comments

Other Hematology or Oncology History

Other Hematology or Oncology History - options

Ongoing

Prior History

Other Hematology or Oncology History Comments

Add dates of other hematology or oncology history and any related comments

4. Surgical History

Surgical History List

Type of Surgery

Approximate Date of Surgery

5. Medications and Immunizations

Current Medications

Please list any medications that you are now taking, including:

Prescriptions (inhalers, injections, creams, patches)
Non-Prescription Medications
Over the Counter Pills
Medical Marijuana
Supplements (CBD)
Herbs
Birth Control Pills/IUD
Home Remedies
As Needed Medications

Prescriptions (inhalers, injections, creams, patches)
Non-Prescription Medications
Over the Counter Pills
Medical Marijuana

Supplements (CBD)
Herbs
Birth Control Pills/IUD
Home Remedies
As Needed Medications

Medication List

Medication Name

Dose

Dose Unit

Frequency

Approximate Start Date

Reason

Medication Allergies

Are you allergic to any medications?*

Yes

Please list any medication allergies that you have.*

Allergy List*

Medication Name

Reaction

Immunization History

Immunization History List

Type of Immunization

Approximate Date of Immunization

Name

This field is for validation purposes and should be left unchanged.

Elligo Patient Registry

1. Contact Information

2. Patient Information

3. Medical History

Dermatology

Pulmonology / Respiratory

Cardiology / Vascular Diseases

Gastroenterology / Hepatology

Urology

Gynecology / Obstetrics

Endocrinology

Neurology / Psychiatry / Pyschology

Orthopedics / Rheumatology

Infections / Parasitic Diseases

Allergy / Immunology

Hematology / Oncology

4. Surgical History

5. Medications and Immunizations

Current Medications

Medication Allergies

Immunization History

Contact Us

Working Hours