Volunteer Registration/Pendaftaran Sukarelawan
Once you have completed this demographic form, you will be included in our Potential Healthy Volunteers Pool. Our recruitment team will get in touch with you as soon as possible. Please stay tuned and have a great day!

Selepas anda mengisi borang demografi ini, nama anda akan tersenarai dalam calon sukarelawan sihat kami. Staf kami akan hubungi anda dalam kadar segera. Teruskan bersama kami!

Personal Information/Maklumat Peribadi
Privacy Note:
Your personal information will not be disclosed to any unauthorized third party.
Notis Privasi :
Maklumat peribadi anda tidak akan didedahkan kepada mana-mana pihak ketiga.
Full Name/Nama Penuh *
Date of Birth/Tarikh Lahir *
MM
/
DD
/
YYYY
Gender/Jantina *
Bangsa/Race *
Marital Status/Status Perkahwinan *
Occupation/Pekerjaan *
Contact Number/Nombor Telefon *
Current Address/Alamat Sekarang *
Basic Health Survey/Soalan Lazim Kesihatan
This information will be used to determine your suitability to participate in studies in Questra. / Maklumat ini akan di gunakan untuk menentukan kesesuaian anda untuk menyertai kajian di Questra.
Weight/Berat badan (kg)
Height/Ketinggian (cm)
Do You Have Any Medical Problem?(If Yes, Please Specify/No) *
Do you have any known allergy?(If Yes, please specify/No) /Adakah anda mempunyai alahan yang diketahui? (Jika Ya, sila nyatakan/Tidak) *
Do you have experiences in participating in any other experimental drug studies?(If Yes, when is your last participation? /No)/Adakah anda mempunyai pengalaman dalam menyertai kajian ubat?(Jika Ya, bilakah penyertaan terakhir anda?/Tidak) *
Have you been hospitalized for any reason?(If Yes, please specify the reason/No)/ Pernahkah anda dimasukkan ke hospital atas sebarang sebab? (Jika Ya, sila nyatakan sebabnya/Tidak) *
Have you donated blood before?(If Yes, when is your last blood donation? /No)/Pernahkah anda menderma darah?(Jika Ya, bilakah pendermaan darah terakhir anda?/Tidak) *
Do you smoke?(If Yes, please specify the quantity of cigarettes you smoke per day/No) /Adakah anda seorang perokok? (Jika Ya, Sila nyatakan bilangan rokok yang anda hisap setiap hari/Tidak) *
Do you consume alcohol?(if Yes, please specify the frequency you drink per week/No) /Adakah anda pernah mengambil minuman beralkohol?(Jika Ya, sila nyatakan kekerapan anda minum dalam seminggu/Tidak) *
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