Most studies enroll 18-50 year old adults of average height and weight and in general good health. As the requirements for each study are different you many not be eligible for participation in all studies.

To see if you may be eligible to participate you may email us some general information on the form provided below. This information will not be used for any other purpose or sold to any other agency. Submitting your information does not obligate you to participate. This information will be kept confidential and a member of the Novum staff will contact you by telephone to determine if you meet eligibility requirements for a specific study and schedule you for a screening appointment.

Date of birth: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , (you must be 18 to 50 years old)

Are you male or female?

How tall are you? feet inch(es)

How much do you weigh? pounds

Are you a smoker or a nonsmoker?

Are you a vegetarian? Yes No

Have you had any illness such as Hepatitis, High Blood Pressure, Stomach Ulcers, Tuberculosis, Diabetes, Seizures, Asthma (since the age of 12), Heart Problems, or Recurring Migraines? Yes No

Have you had any disease of the stomach, intestines, kidneys, liver, or heart? Yes No

Do you currently have psoriasis, eczema, or any other skin condition? Yes No

Do you have a medical condition requiring regular treatment with prescription or over-the-counter medications? (birth control medication does not apply) Yes No

Have you had any psychiatric disorders requiring treatment or medication in the past year? Yes No

Do you have a history of chronic alcohol consumption or drug addiction? Yes No

When are you available to do studies? Weekends only Weekdays only Anytime

When is the best time to contact you? 8 AM to 10 AM 10 AM to 12 PM 12 PM to 2 PM 2 PM to 4 PM 4 PM to 6 PM 6 PM to 8 PM

Thank you for your interest in participating in a clinical research study at Novum. A representative at Novum will contact you shortly.