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Questionnaire clinical studies

To be able to assess your eligibility for one of these clinical studies, we ask you to complete the questionnaire below. This way, we can ensure a smooth flow to the study for which you may or may not be eligible. Naturally, these data will be kept and treated strictly confidentially in our database within the framework of medical secrecy.

Step 1 of 9

11%

  • Personal data

  • Occupational and living situation

  • GP

  • Medical data

  • Length in cm
  • Weight in kg

  • Current medication

  • e.g. Omeprazole - 40mg per day - since 2009 or e.g. Bisoprolol - 2x5mg per day - 28/02/2005

  • Other questions

  • Medical conditions

  • Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

  • Field of interest for Medical studies

    You may fill in one or more choices. This choice gives us insight into your field of interest and will help us streamline your choice of information and participation.

  • Consent to data retention

  • I understand that my personal details* will end up in the Anima bvba file of candidates as a result of this registration. If you do take part in a study, this data will be kept in Anima bvba's candidate file for 25 years. If you do not participate in an ARC study, you can request the permanent removal of your data from the Anima bvba candidate file. If you wish to do so, please send an e-mail with that request, stating your name and date of birth to dpo@anima-alken.be .

    Your details will only be kept internally (Anima bvba) and in the strictest confidence, and will never be passed on to third parties.
    * Personal details: name, date of birth and contact details. If you have provided medical information to Anima bvba, which according to our study doctors can be crucial in assessing whether you should participate in a subsequent study, this information will also be saved. This information will never be made available for inspection by third parties.

Follow us:

ANIMA RESEARCH CENTER

Alkerstraat 28-30-30A-32z
3570 Alken
Belgium

Science Park 11-13
3590 Diepenbeek
Belgium

 

info.arc@anima-alken.be
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