Aids clinical trials unit


Mailing Information:
City, State, ZIP:
E mail Address:
Date of Birth:
Would you like to be entered into our data base?
Yes No
Would you like to receive mailings about
Via E mail ? Yes No N/A
studies and events at the above address?
Phone Number Home :

Phone Number Work :
May we call you home? Yes No
May we call you at work? Yes No
Primary Physician / Clinic:
How did you hear about us?
Opportunistic Infections :
__________________________________ Date :___________________
__________________________________ Date :___________________
__________________________________ Date :___________________
__________________________________ Date :___________________
Tcells - most recent count :
Tcells - most recent date :
RNA - most recent count :
RNA - most recent date :

Antiretroviral Therapy : (Please include any past use as well)
Date Started Date Stopped If Stopped, why?
AZT (Zidovudine, Retrovir)
ddI (Didanosine, Videx
ddC (Zalcitabine, Hivid)
d4T (Stavudine, Zerit)
3TC (Lamivudine, Epivir)
Combivir (AZT + 3TC)
Efavirenz (Sustiva)
Antiretroviral Therapy - Continue: (Please include any past use as well)
Date Started Date Stopped If Stopped, why?
Adefovir ( Preveon)
Abacavir (1592U89, Ziagen)
Amprenavir ( 141W94,
Saquinavir hard gel cap (Invirase)
Saquinavir soft gel cap
Nelfinavir ( Viracept )
Ritonavir (Norvir)
Indinavir ( Crixivan)
Delavirdine (Rescriptor)
Nevirapine (Viramune)
ABT - 378/r
Prophylaxis/Other (please circle ALL taken)
Septra Dapsone A.Pentamidine Atovaquone Azythromycin Clarithromycin
Ethambutol Oral Ganciclovir rhNGF (human nerve Growth factor) HIV vaccines
Hydroxyurea GP 160 IL - 2
Other : _______________ ________________ ________________ ______________ ___________
In which studies are you interested?
Comments: __________________________________________________________________________________

Please complete this questionnaire and return it to : Stanford University medical Center

Or fax to (650) 498-7874

For ACTU use only
Screened : Y N Protocol ___________
Excluded : Y N If "Y" - reason _________________________________________________


Microsoft word - emergencymedicalform

St. Joseph Consolidated School Emergency Medical Authorization Form 2013-2014 Purpose- To enable parents to authorize emergency treatment for children who become ill or injured while under school authority when parents cannot be reached. One form for each student must be filled out. Please complete BOTH sides Student Name: _______________________________Parent Name:__________

Microsoft word - trousse pharmacie.doc

TROUSSE DE PHARMACIE Contre les piqûres d’insectes ‰ Répulsifs sur la peau (le matin, au « dessus » de la crème solaire, et à la à base de DEET (concentration minimale de 30%) ou de Picaridine (20 à 30%) ex: INSECT Ecran spécial Tropiques® ou de IR 35/35 (20 à 35%) ex : CINQ sur CINQ tropic ® – Moustifluid zones tropicales ® ou de citriodiol (20 à 30%) e

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