Clinilabs Inc.

Anxiety Online Questionnaire

Please complete the following online questionnaire to determine if you may qualify for a research study of an investigational medication. This study involves 1 daytime office visit and a 6 day inpatient stay at our Midtown clinic over a period of approximately 4 weeks. Financial compensation will be provided to qualified subjects.

Name:	Address:
Email: Yes, email me to confirm study appointments and to contact me about new studies I may qualify for.	Phone (Home):
Age:	Phone (Work):
	Phone (Mobile): Yes, text me regarding new studies that I may qualify for.
1.	Male Female
2. Are you between 18 to 45 years of age?	Yes No
3. Please list all medication including prescription, over-the-counter, vitamins, herbals, supplements, diet pills, sleep aids you have taken in the past 2 weeks.
4. Do you smoke?	Yes No
5. Have you been diagnosed with generalized anxiety disorder (GAD)?	Yes No
6. Have you ever received any treatment such as medication or therapy for generalized anxiety disorder?	Yes No If yes, please explain.
7. Have you been diagnosed with any of the following psychological conditions? Select all that apply.
8. Clinilabs has various clinical trials being conducted throughout the year. Do we have your permission to retain your information in our database and contact you regarding participation in future studies?	Yes No
I have read and understand the terms and conditions. Agree Disagree	Terms and Conditions Information and Collection Use When you submit information to Clinilabs by completing one of our Web-based questionnaires, you voluntarily provide information which may include one or all of the following: your name, address, city, state, zip code, telephone number, e-mail address, health information, and similar identifying information. We also may request additional information from you at the time you register or complete a Web-based questionnaire, or at some time thereafter. Once you register or submit a Web-based questionnaire to Clinilabs you are not anonymous to us. Your information will be stored in the Clinilabs patient database. A member of the Clinilabs Research division will review your information to determine your eligibility to participate in one of our current and upcoming studies. If you do not wish to provide some or all of the information requested on a questionnaire, or if you have concerns about maintaining the confidentiality of any information, do not provide it. If at any time you want to remove your information from the database after you provided it to Clinilabs, you can notify a member of the Clinilabs Research division to remove it. The Way We Use Information We use the information you provide about yourself only for the purposes set forth in the website. We do not share this information with outside parties except to the extent necessary to complete that order. We use return email addresses to answer the email we receive. Such addresses are not used for any other purpose and are not shared with outside parties. We use non-identifying and aggregate information to better design our website and to share with management consultants. For example, we may tell a management consultant that X number of individuals visited a certain area on our website, or that Y number of men and Z number of women filled out our registration form, but we would not disclose anything that could be used to identify those individuals. Finally, we never use or share the personally identifiable information provided to us online in ways unrelated to the ones described above without also providing you an opportunity to opt-out or otherwise prohibit such unrelated uses. Information Sharing and Disclosure Clinilabs will not sell or rent your personal information to third parties without your consent. If you consent to release information to a third party who obtains information about you from thisWebsite, that party is required to obtain your consent and treat such information as confidential. Clinilabs may disclose personal information about you to a business partner or other company when: -We have obtained your permission to share such information -We need to respond to court orders, subpoenas, or other legal requests Our Commitment To Data Security To prevent unauthorized access, maintain data accuracy, and ensure the correct use of information,we have put in place appropriate physical, electronic, and managerial procedures to safeguard and secure the information we collect online. Our Commitment To Children's Privacy Protecting the privacy of the very young is especially important. For that reason, we never collect or maintain information at our website from those we actually know are under 13, and no part of our website is structured to attract anyone under 13.

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