researchindex

Member of the Endocrine Associates of Dallas, PA

TEL 214.265.2137 FAX 214.265.2164

Director
Stephen Aronoff, M.D., F.A.C.P., F.A.C.E.

Medical Board
Richard Sachson, M.D., F.A.C.P., F.A.C.E.
Steven Dorfman, M.D. F.A.C.P., F.A.C.E.
Mitchell Sorsby, M.D. F.A.C.E.
Audrey Miklius, M.D., F.A.C.E.
S.K. Lakhian, M.D., F.R.C.P. (C)
Heidi Chamberlain Shea, M.D., F.A.A.P.

The mission of Research Institute of Dallas, P.A. is to provide the clinical research industry with a facility that continuously strives to conduct cost efficient Phase II - IV clinical trials while demonstrating integrity and compassion for our patients.

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PATIENT INFORMATION

CURRENT MEDICATIONS

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    SURGICAL HISTORY

OTHER SERIOUS ILLNESSES

PLEASE ANSWER YES OR NO TO THE FOLLOWING. CHECK AS MANY AS APPLIES.

YES NO	Anemia	YES NO	Depression	YES NO	Elevated Cholesterol
YES NO	Elevated Triglycerides	YES NO	Heart Problems	YES NO	Hypertension
YES NO	Hypothyroid	YES NO	Menopause	YES NO	Migraines
YES NO	Nephropathy	YES NO	Neuropathy	YES NO	Obesity
YES NO	Osteoporosis	YES NO	Retinopathy	YES NO	Impotence
YES NO	Diabetes Type 1	YES NO	Diabetes Type 2

YES NO

May we have permission to enter the information you have provided into our clinic database for future reference?