Patient Contact Form

C.A.R.E. Clinical Research is one of many sites performing investigational drug studies, medical research and clinical trials in St. Louis Missouri. Currently we are studying new medications and treatments for Emphysema, COPD, Bronchitis, Asthma, Hypertension, Stroke, Atrial Fibrillation and Deep Venous Thrombosis. If you are interested in participating or learning more about any of these studies please fill out this form or call 314-699-9383 and one of our staff members will assist you.

Contact Information

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Medical History

Please Check Yes Or No For The Following Indications

Do you currently/past smoked cigarettes?

Diagnosed emphysema or COPD?

Diagnosed Chronic Bronchitis ?

Diagnosed Asthma?

Diagnosed Hypertension?

Diagnosed Atrial Fibrillation?

Diagnosed DVT or Bloot Clots ?

Diagnosed Heart Disease?

Have you had a previous stroke?

Diagnosed High Cholesterol ?

Diagnosed Diabetes ?

Diagnosed Anxiety ?

Diagnosed Gout ?

Diagnosed Pain ?



Are you currently taking any medication?

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