IRSI | Recruiting | Panelist Registration Form

Providing quality clinical results for over 30 years.

Panelist Registration Form...

This questionnaire will be used as an aid in recruiting paid volunteers. The information provided will be entered into the IRSI computer. Some government agencies and others in certain legal action may gain access to this information. The information will otherwise remain confidential in its use for IRSI business purposes. Please answer the questions honestly; we recruit people with or without the conditions listed below.

Last Name

First Name/Initial

Address

City

State

Zip

Country

Home Phone

Work Phone

Cell Phone

Sex

Female Male

Date of Birth

Race (Optional)

Parent or Guardian (If under age 18)

Email

Please check each of these common conditions you might have:

Acid Indigestion/Heartburn
Acne
Arthritis
Asthma
Atopic Dermatitis or Eczema
Constipation
Contact Lens Wearer
Dandruff
Denture Wearer
Diabetes—Insulin Dependent
Diabetes—Non-Insulin Dependent
Dry Skin
Hair Loss

Headaches—Stress Releated
Headaches—Migraine
Hemorrhoids
Insomnia/Trouble Sleeping
Back Pain
Oily Skin
Psoriasis
Rosacea
Seborrheic Dermatitis
Seasonal Allergies
Sensitive Skin
Smoker
Use Cosmetics Regularly

Do you take medication on a regular basis?

Anti-Inflamatories: aspirin, Advil®, Aleve®, Motrin®, etc.
Antihistamines: most allergy/cold/flu medications
Asthma therapy
Cholesterol-Lowering Drugs

Diabetes
Hypertension
Thyroid
Other:

Please check types of studies of interest to you:

Six-Week Patch Test of Allergic Reaction to Skin Care Products (15 visits to IRSI)
One or Two-Visit Study at IRSI (No home use required)
Testing Cosmetics or Personal Care Products at Home (two or more visits To IRSI)

When are you usually available for studies?

Weekdays—Flexible Schedule
Weekdays—Mornings Only
Weekdays—Lunch Hour Only

Weekdays—Afternoons Only
Weekdays—Weekends or Evenings Only

Who Referred You?

Questions/Comments: