
Participating cities:

	Missouri Springfield St. Louis North Carolina Charlotte Raleigh Tennessee Clarksville Nashville Virginia Virginia Beach

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What is a clinical trial?

Pre-Qualifying Questionnaire

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

These questions are to be answered by the person who would be enrolled in the study if they qualify. If you are visiting this website for someone else, please provide the website link to them so that they may complete the questionnaire themselves.

As used in these questions, "you" or "your" refers to the person who would be enrolled in the study if they qualify.

Please enter your home zip code.

Enter 5-digit zip code.

What is your date of birth?

Month
Day	ex. 08
Year	ex. 1954

What is your gender?

Female Male

For the last year or longer, have you been experiencing headaches that typically last between 4 and 72 hours?

Yes No

Has a physician diagnosed you as having coronary artery disease (CAD, commonly known as heart disease) based upon an angiogram or stress test? (An angiogram is an x-ray, CT or MRI study of the heart. A stress test is a test in which you are on a treadmill or other exercise equipment and your heart is monitored.)

	Yes, I have been physician diagnosed with coronary artery disease (CAD)
	No, I have not been physician diagnosed with coronary artery disease (CAD)
	Unsure

Have you had a heart attack?

	Yes, I have had a heart attack
	No, I have not had a heart attack

Has a physician diagnosed you as having myocardial ischemia? (Myocardial ischemia is a disease caused by reduced blood supply to the heart. Sometimes, chest pain will be a symptom of myocardial ischemia. Other times, myocardial ischemia has no symptoms, and when that occurs it may be called “silent ischemia.”)

	Yes, I have been physician diagnosed with myocardial ischemia
	No, I have not been physician diagnosed with myocardial ischemia
	Unsure

Has a physician told you that you had a heart attack although you were not aware of it, a condition that may be called a “silent heart attack”?

Yes No Unsure

Have you had heart bypass surgery?

	Yes, I have had heart bypass surgery
	No, I have not had heart bypass surgery

10.

Have you had an angioplasty procedure? (Angioplasty is a medical procedure whereby a balloon tipped tube (a catheter) is inserted into an artery in the groin and then moved up to an artery in the heart where the balloon is expanded to widen the artery. A stent may also be placed in the artery of the heart during this procedure.)

	Yes, I have had a angioplasty procedure
	No, I have not had an angioplasty procedure

11.

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. If you provide your or a friend´s/family member´s email address, the email address will not be provided to anyone other than the person to whom the email was sent as specified in this website. We will keep the information you provide on file for up to three years for auditing purposes only.

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