Fibromyalgia Research Study


Participating cities:

	Arizona Phoenix California Anaheim Burbank Carmichael Fair Oaks Fullerton Irvine Northridge Pismo Beach Sacramento Florida Largo Miami Orlando St. Petersburg Tampa Zephyrhills Georgia Marietta Idaho Coeur d'Alene Illinois Chicago Indiana Indianapolis Kentucky Elizabethtown Lexington Louisiana Baton Rouge Maryland Rockville Michigan Benzonia Interlochen Missouri St. Louis Nebraska Omaha New Jersey Berlin New Mexico Albuquerque North Carolina Winston-Salem Oregon Portland Pennsylvania Duncansville Texas Austin Fort Worth Houston San Antonio Sugar Land Waco

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Pre-Qualifying Questionnaire	To see if you might qualify for this medical research study, please complete this Pre-Qualifying Questionnaire.

Are you filling this questionnaire out for yourself?

Yes No

Please enter your home zip code.

What is your date of birth?

Month
Day	ex. 08
Year	ex. 1954

4.	What is your gender?
	Female Male

5.	Have you been diagnosed by a physician as having Fibromyalgia?
	Yes No

6.	How did you hear about this study?

Privacy Policy: If you pre-qualify for this study, you will be given a choice to submit your contact information along with your answers to the questionnaire to a study clinic conducting this study. If you make this choice, your information will only be shared with those conducting the medical research study and will not be shared or provided to any other person or business not related to this particular study. Except as noted above, no personally-identifiable information will be taken from you and your answers will remain confidential.

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