Altasciences is seeking men and women 18 years and older, suffering from: Type l or ll Diabetes Asthma Hepatitis A, B or C Hepatic impairment Rheumatoid arthritis Low testosterone Personal information First name * Last name * Gender * Male Female Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Smoking habits * Smoker Non-smoker Body Mass Index Imperial (pi) Metric (m) Height ' Height (inches) " Height m Height (cm) cm Weight kg Your BMI : Join us Phone * eg. 555 444-3333 Ext. Optional E-mail Postal code/Zip code * eg. H0H 0H0 Special conditions List conditions Diabetes Asthma Hepatitis Rheumatoid arthritis Low testosterone Hepatic impairment Agreement * I agree with the terms and conditions: PIPEDA Verbal Consent Agreement Message In order to better serve you, we must collect some personal information before we can give any details about our current research studies or give you an appointment for your health evaluation. This procedure allows us to verify if you fit the criteria for our clinical trials. Your personal information will be kept under strict confidentiality and only our authorized employees, qualified government agencies and our sponsors will have access to it. You can at all-time contact our Chief Privacy Officer to consult and modify your personal information or to remove your name from our contact list. If you would like to know more about our policy on the privacy of your personal information, please ask for our brochure at the screening center or write to our Chief Privacy Officer at 575 Armand-Frappier, Qc, Canada, H7V 4B3, or email: firstname.lastname@example.org or dial this number: (450) 973-6077 or (701) 356-4000. Do you authorize us to collect the required personal information? If you don't agree, we cannot give you details about on-going clinical studies or schedule an appointment with you for a health evaluation.