* denotes mandatory field Name* First Last Date of Birth* Gender*MaleFemaleHeight (cm)*Weight (kg)*Contact DetailsBest Contact Phone Number*Alternative Phone NumberEmail* How did you hear about us?FacebookRadioJob SiteFriendCCST websiteSmoking HistoryI am a*SmokerNon-SmokerPrevious SmokerYear last smoked*No. of cigarettes per day*Medical HistoryList any medications that you take regularly (including herbal remedies, supplements or any contraceptive therapy)List all known allergies List any known medical conditions I consent to CCST holding the information given above on a database and understand this information will remain confidential and only be used by CCST and to be contacted for suitable studies* Consent given The NZ Health and Disability Ethics Committee has approved our site to collect and store this personal health information. All data collected is stored in a safe and secure environment. Thank you for taking the time to complete this questionnaire. Please review your responses to ensure all prompts have been answered accurately so that you may be contacted regarding clinical trials which are relevant to you. NameThis field is for validation purposes and should be left unchanged.