{"id":171,"date":"2019-11-05T18:39:44","date_gmt":"2019-11-05T18:39:44","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/imu\/?page_id=171"},"modified":"2020-01-08T13:52:03","modified_gmt":"2020-01-08T13:52:03","slug":"registration","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/imu\/registration\/","title":{"rendered":"Registration"},"content":{"rendered":"<h5>Interested in participating a clinical trial? Kindly fill in the form below and we will get back to you.<br \/>\nTo change registration details, Kindly click\u00a0<a href=\"https:\/\/medicine.nus.edu.sg\/imu\/change-of-registration-details\/\"> here.<\/a><\/h5>\n<p>&nbsp;<\/p>\n<h5>Personal Data Protection Act (\u201cPDPA\u201d)<\/h5>\n<p>Under the Personal Data Protection Act (\u201cPDPA\u201d) which governs the collection, use and disclosure of personal data, IMU is committed to safeguarding all of your personal data that we may possess.<\/p>\n<p>Data captured in the IMU Healthy Volunteer Database is kept confidential with password protection and restricted access.<\/p>\n<p>We fully respect your privacy and will not sell or disclose your data to third parties. We will only disclose your personal data to third parties in order to comply with legal obligations or industry requirements. Such third parties include legal, regulatory, governmental, and law enforcement authorities.<\/p>\n<p>By registering to become a volunteer, we will share with you any future biomedical research\/study conducted in IMU and NUH as approved by an ethics review committee in which you may be interested to participate.<\/p>\n<p>You are free to withdraw your consent at any time, should you wish to no longer be contacted for future trials or research studies.<\/p>\n<p>Do you understand and agree the terms stated in Personal Data Protection Act?<span class=\"gfield_required\">*<\/span><\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/imu\/wp-json\/wp\/v2\/pages\/171#gf_3' data-formid='3' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_29\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_29\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Do you understand and agree the terms stated in Personal Data Protection Act?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_29'><li class='gchoice gchoice_3_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Yes, I understand and agree to the terms mentioned in PDPA.'  id='choice_3_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_29_1' id='label_3_29_1' class='gform-field-label gform-field-label--type-inline'>Yes, I understand and agree to the terms mentioned in PDPA.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_31\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_31\"><h2 class=\"gsection_title\">Personal Particulars (*mandatory to fill in)<\/h2><\/li><li id=\"field_3_32\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_32\"><label class='gfield_label gform-field-label' for='input_3_32' >Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_3_32' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_2\"  class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_2\"><label class='gfield_label gform-field-label'  >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_3_2' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_3_2_2_container'><select name='input_2[]' id='input_3_2_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_3_2_1_container'><select name='input_2[]' id='input_3_2_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_3_2_3_container'><select name='input_2[]' id='input_3_2_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_3_3\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\"><label class='gfield_label gform-field-label'  >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_3'>\n\t\t\t<li class='gchoice gchoice_3_3_0'>\n\t\t\t\t<input name='input_3' type='radio' value='Male' checked='checked' id='choice_3_3_0'    \/>\n\t\t\t\t<label for='choice_3_3_0' id='label_3_3_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_3_1'>\n\t\t\t\t<input name='input_3' type='radio' value='Female'  id='choice_3_3_1'    \/>\n\t\t\t\t<label for='choice_3_3_1' id='label_3_3_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_4\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\"><label class='gfield_label gform-field-label'  >Ethnicity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_4'>\n\t\t\t<li class='gchoice gchoice_3_4_0'>\n\t\t\t\t<input name='input_4' type='radio' value='Chinese'  id='choice_3_4_0'    \/>\n\t\t\t\t<label for='choice_3_4_0' id='label_3_4_0' class='gform-field-label gform-field-label--type-inline'>Chinese<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_4_1'>\n\t\t\t\t<input name='input_4' type='radio' value='Malay'  id='choice_3_4_1'    \/>\n\t\t\t\t<label for='choice_3_4_1' id='label_3_4_1' class='gform-field-label gform-field-label--type-inline'>Malay<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_4_2'>\n\t\t\t\t<input name='input_4' type='radio' value='Indian'  id='choice_3_4_2'    \/>\n\t\t\t\t<label for='choice_3_4_2' id='label_3_4_2' class='gform-field-label gform-field-label--type-inline'>Indian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_4_3'>\n\t\t\t\t<input name='input_4' type='radio' value='Caucasian'  id='choice_3_4_3'    \/>\n\t\t\t\t<label for='choice_3_4_3' id='label_3_4_3' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_4_4'>\n\t\t\t\t<input name='input_4' type='radio' value='gf_other_choice'  id='choice_3_4_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_3_4_other' name='input_4_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_5\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_3_5_container'>\n                                <span id='input_3_5_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='text' name='input_5' id='input_3_5' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_3_5' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_3_5_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='text' name='input_5_2' id='input_3_5_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_3_5_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_3_6\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_6\"><label class='gfield_label gform-field-label' for='input_3_6' >Contact number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_3_6' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_37\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_37\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Preferred mode of contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_37'><li class='gchoice gchoice_3_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Text Message'  id='choice_3_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_1' id='label_3_37_1' class='gform-field-label gform-field-label--type-inline'>Text Message<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Phone Call'  id='choice_3_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_2' id='label_3_37_2' class='gform-field-label gform-field-label--type-inline'>Phone Call<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Email'  id='choice_3_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_3' id='label_3_37_3' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_9\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_9\"><h2 class=\"gsection_title\">Social History<\/h2><\/li><li id=\"field_3_10\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_10\"><label class='gfield_label gform-field-label'  >Any known drug allergies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_10'>\n\t\t\t<li class='gchoice gchoice_3_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Yes' checked='checked' id='choice_3_10_0'    \/>\n\t\t\t\t<label for='choice_3_10_0' id='label_3_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='No'  id='choice_3_10_1'    \/>\n\t\t\t\t<label for='choice_3_10_1' id='label_3_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_11\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_11\"><label class='gfield_label gform-field-label' for='input_3_11' >Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_3_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_12\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\"><label class='gfield_label gform-field-label'  >Any smoking history?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_12'>\n\t\t\t<li class='gchoice gchoice_3_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Yes'  id='choice_3_12_0'    \/>\n\t\t\t\t<label for='choice_3_12_0' id='label_3_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Social'  id='choice_3_12_1'    \/>\n\t\t\t\t<label for='choice_3_12_1' id='label_3_12_1' class='gform-field-label gform-field-label--type-inline'>Social<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='No' checked='checked' id='choice_3_12_2'    \/>\n\t\t\t\t<label for='choice_3_12_2' id='label_3_12_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_12_3'>\n\t\t\t\t<input name='input_12' type='radio' value='Ex-smoker'  id='choice_3_12_3'    \/>\n\t\t\t\t<label for='choice_3_12_3' id='label_3_12_3' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_14\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_14\"><label class='gfield_label gform-field-label' for='input_3_14' >Number of cigarettes per day<\/label><div class='ginput_container ginput_container_number'><input name='input_14' id='input_3_14' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_3_15\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_15\"><label class='gfield_label gform-field-label'  >Have you consumed Alcohol in the past week?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_15'>\n\t\t\t<li class='gchoice gchoice_3_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_3_15_0'    \/>\n\t\t\t\t<label for='choice_3_15_0' id='label_3_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No' checked='checked' id='choice_3_15_1'    \/>\n\t\t\t\t<label for='choice_3_15_1' id='label_3_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='Social'  id='choice_3_15_2'    \/>\n\t\t\t\t<label for='choice_3_15_2' id='label_3_15_2' class='gform-field-label gform-field-label--type-inline'>Social<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_16\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_16\"><label class='gfield_label gform-field-label' for='input_3_16' >Number of glasses per week<\/label><div class='ginput_container ginput_container_number'><input name='input_16' id='input_3_16' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_3_17\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_17\"><label class='gfield_label gform-field-label' for='input_3_17' >Type of alcohol<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_3_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\"><label class='gfield_label gform-field-label'  >Use of recreational drugs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_18'>\n\t\t\t<li class='gchoice gchoice_3_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_3_18_0'    \/>\n\t\t\t\t<label for='choice_3_18_0' id='label_3_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No' checked='checked' id='choice_3_18_1'    \/>\n\t\t\t\t<label for='choice_3_18_1' id='label_3_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_19\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_19\"><label class='gfield_label gform-field-label' for='input_3_19' >Please specify drug<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_3_19' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_20\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_20\"><label class='gfield_label gform-field-label'  >Currently on any medication or health supplements<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_20'>\n\t\t\t<li class='gchoice gchoice_3_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Yes'  id='choice_3_20_0'    \/>\n\t\t\t\t<label for='choice_3_20_0' id='label_3_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='No' checked='checked' id='choice_3_20_1'    \/>\n\t\t\t\t<label for='choice_3_20_1' id='label_3_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_21\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\"><label class='gfield_label gform-field-label' for='input_3_21' >Please specify the medication<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_3_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_22\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_22\"><label class='gfield_label gform-field-label'  >Do you suffer from any health issues<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_22'>\n\t\t\t<li class='gchoice gchoice_3_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Yes'  id='choice_3_22_0'    \/>\n\t\t\t\t<label for='choice_3_22_0' id='label_3_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='No' checked='checked' id='choice_3_22_1'    \/>\n\t\t\t\t<label for='choice_3_22_1' id='label_3_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_23\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_23\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Please select the relevant medical conditions (You may select more than one)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_23'><li class='gchoice gchoice_3_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Asthma'  id='choice_3_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Chronic Obstructive Pulmonary Disorder ( COPD )'  id='choice_3_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_2' id='label_3_23_2' class='gform-field-label gform-field-label--type-inline'>Chronic Obstructive Pulmonary Disorder ( COPD )<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Diabetes'  id='choice_3_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_3' id='label_3_23_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Hypertension ( High Blood Pressure )'  id='choice_3_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_4' id='label_3_23_4' class='gform-field-label gform-field-label--type-inline'>Hypertension ( High Blood Pressure )<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='High Blood Cholesterol'  id='choice_3_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_5' id='label_3_23_5' class='gform-field-label gform-field-label--type-inline'>High Blood Cholesterol<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_23_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.6' type='checkbox'  value='Stroke'  id='choice_3_23_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_6' id='label_3_23_6' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_23_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.7' type='checkbox'  value='Eczema'  id='choice_3_23_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_7' id='label_3_23_7' class='gform-field-label gform-field-label--type-inline'>Eczema<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_23_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.8' type='checkbox'  value='Others'  id='choice_3_23_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_8' id='label_3_23_8' class='gform-field-label gform-field-label--type-inline'>Others<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_24\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_24\"><label class='gfield_label gform-field-label' for='input_3_24' >Please specify other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_3_24' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_38\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_38\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Do you have a therapeutic area of clinical trial which you are interested in?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_38'><li class='gchoice gchoice_select_all'>\n\t\t\t\t\t\t<input class='gfield-choice-input' type='checkbox' id='choice_38_select_all'   onclick='gformToggleCheckboxes( this )' onkeypress='gformToggleCheckboxes( this )' \/>\n\t\t\t\t\t\t<label for='choice_38_select_all' id='label_38_select_all' class='gform-field-label  gform-field-label--type-inline' data-label-select='Select All' data-label-deselect='Deselect All'>Select All<\/label>\n\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Cardiology'  id='choice_3_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_1' id='label_3_38_1' class='gform-field-label gform-field-label--type-inline'>Cardiology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Dermatology'  id='choice_3_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_2' id='label_3_38_2' class='gform-field-label gform-field-label--type-inline'>Dermatology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Endocrinology'  id='choice_3_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_3' id='label_3_38_3' class='gform-field-label gform-field-label--type-inline'>Endocrinology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Gastroenterology'  id='choice_3_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_4' id='label_3_38_4' class='gform-field-label gform-field-label--type-inline'>Gastroenterology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Geriatric Medicine'  id='choice_3_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_5' id='label_3_38_5' class='gform-field-label gform-field-label--type-inline'>Geriatric Medicine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Haematology\/Oncology'  id='choice_3_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_6' id='label_3_38_6' class='gform-field-label gform-field-label--type-inline'>Haematology\/Oncology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.7' type='checkbox'  value='Infectious Disease'  id='choice_3_38_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_7' id='label_3_38_7' class='gform-field-label gform-field-label--type-inline'>Infectious Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.8' type='checkbox'  value='Neurology'  id='choice_3_38_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_8' id='label_3_38_8' class='gform-field-label gform-field-label--type-inline'>Neurology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.9' type='checkbox'  value='Obstetrics &amp; Gynaecology'  id='choice_3_38_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_9' id='label_3_38_9' class='gform-field-label gform-field-label--type-inline'>Obstetrics & Gynaecology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.11' type='checkbox'  value='Ophthalmology'  id='choice_3_38_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_11' id='label_3_38_11' class='gform-field-label gform-field-label--type-inline'>Ophthalmology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.12' type='checkbox'  value='Orthopaedic Surgery'  id='choice_3_38_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_12' id='label_3_38_12' class='gform-field-label gform-field-label--type-inline'>Orthopaedic Surgery<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.13' type='checkbox'  value='Otorhinolaryngology\/ENT'  id='choice_3_38_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_13' id='label_3_38_13' class='gform-field-label gform-field-label--type-inline'>Otorhinolaryngology\/ENT<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.14' type='checkbox'  value='Psychiatry'  id='choice_3_38_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_14' id='label_3_38_14' class='gform-field-label gform-field-label--type-inline'>Psychiatry<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_38_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.15' type='checkbox'  value='Public Health'  id='choice_3_38_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_15' id='label_3_38_15' class='gform-field-label gform-field-label--type-inline'>Public Health<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice 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