Healthy Japanese + Chinese Adult Clinical Trials

Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

Yes

First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code *

What sex were you assigned at birth? *

Male

Female

Prefer not to answer

Where were you born? *

I was born in the USA

I was born in Japan

I was born in China

Other

In general, how would you rate your health? *

Excellent

Very Good

Good

Fair

Poor

Have you been diagnosed (by a doctor) with any medical conditions? *
(For example: Epilepsy, dysplasia, lymphoma, leukemia, tuberculosis).
Please list here or write 'none'
Please only include conditions which have been diagnosed by a doctor.

Are you taking any medications for your health conditions? *
Please list them below or type ‘none’.

Do you have any allergies to certain foods or medications? *

Yes - food allergies

Yes - medication allergies

No

Are you currently taking any medications (including prescription and/or over the counter)? *

Yes No

Will you be willing to discontinue the use of herbal remedies, or supplements for 2 weeks before a screening visit and until the study completes? *

Yes

No

Unsure

In the last 6 months, have you used any tobacco or nicotine products? *

Yes No

Are you comfortable having multiple blood draws during the duration of the study? *

Yes

No

Unsure

Are you willing to travel to a research facility (including a first screening visit and multiple visits over 4 months of participation for a study)? *
Please note: The facility may be out of state in Grayslake, Illinois. Participants may receive up to $500 for screening at the facility. While travel reimbursement is not available for screening - For the remainder of visits, if selected for a study, long-distance travel will qualify for all travel reimbursement and eligible participants may be compensated up to $13,000 for completion of a study.

Yes

No

Unsure

Are you willing to stay overnight at a research facility? *

Yes

No

Unsure

Please, select your height from the dropdown below. *

How much do you weigh in Lbs (pounds)? *

What is the best day/time to reach you via telephone (we know you are busy)? *

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible? To opt out, reply “STOP”. For customer care or support, text “HELP”. Message and data rates may apply. Message frequency varies. By clicking “Yes”, you also agree to our SMS Terms and Privacy Policy. *

Yes No

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.

Healthy Japanese + Chinese Adult Clinical Trials

We’re enrolling adults to take part in studies evaluating investigational medication that may help researchers treat fibrotic lung diseases.

Study benefits include:

Eligible participants must be: