Research Participant Registration Form

For  Aranda MD Enterprises PMA's Research Studies

Now that you have become a member of the Geared Research Network by reviewing and signing the PMA and Trust agreements, we need to collect your profile and medical history information. 

All of this information is private and confidential and will only be used for research purposes anonymously. It will not be sold nor provided to 3rd parties outside of the Network. 

Profile Information
Mobile Phone # - Numbers only.
Medical History
Height
feet
inches
Gender
COVID-19 Vaccines
Which COVID-19 Vaccine did you take?
Medical Problems
Complications of Covid
a disorder of the autonomic nervous system. This branch of the nervous system regulates functions we don't consciously control, such as heart rate, blood pressure, sweating and body temperature.
Past Surgeries
Family History
Mother
Father
Social History
Cigarettes
Alcohol
(Drinks per week)
(Drinks per week)
(Drinks per Week)
Marijuana
Marijuana Intake Process:
Heroin
Psilocybin:
Research Administrator Information
Survey Willingess
I agree to participate in research surveys. 
Survey Communication Preference
How would you like us to send you the survey forms?
Send to my email above.
Send to my mobile number above.
Send both email and text.