Colorado Questionnaires

Update on COVID-19

To: Our Sponsors, CROs, Patients, and Employees

At CenExel Clinical Research, our top priorities are the safety and health of our patients and employees. For our Centers of Excellence to provide the highest quality of clinical research, we established and maintain a COVID-19 Task Force with representatives from every Center. The Task Force is charged with continuous monitoring of the pandemic and providing guidance and communication.

Our clinical operations continue, and we have implemented the following additional safety measures:

Enhanced screening of everyone entering any of our facilities before they are admitted into our offices or clinical areas
Reinforced internal communication regarding the COVID-19 situation, CDC and SHRM recommendations, digital team meetings, and the importance of using sick leave for anyone who has signs, symptoms, or recent exposure to someone with suspected or diagnosed COVID-19
Additional cleaning and disinfecting materials provided through our clinic and office areas
Cross-training and preparations for contingency plans if key staff need to stay home

We will continue to monitor the current situation, coordinate with the proper authorities, and update our policies and procedures as needed to ensure the safety of our patients and employees.

Colorado Questionnaires

Weight Loss & Type II Diabetes Questionnaire

Your Name(Required)

First Last

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Birth Date(Required)

Sex(Required)

Height (feet/inches)(Required)

Weight (pounds)(Required)

Weight History

Have you been diagnosed with Type II Diabetes?(Required)

Have you ever experienced retinopathy, ketoacidosis, hypoglycemia, etc.?

What was your last HbA1c?(Required)

Are you on insulin?(Required)

Have you taken any weight loss surgeries, medications, or supplements in the past?(Required)

If yes, when? What kind?

Have you participated in any other weight loss programs?(Required)

If yes, when? What program?

Are you willing to track your diet and exercise during the study?(Required)

Medical History

Do you have high blood pressure?

Do you have low/high cholesterol?

Do you have sleep apnea?

Do you have cardiovascular disease?

If yes, specify diagnosis.

Have you had a heart attack or been hospitalized for your heart?

Have you had any abnormal lab results (i.e. hypo/hyperthyroidism, anemia, kidney/liver dysfunction, etc.)?

If yes, specify diagnosis.

Do you have any psychiatric conditions?

If yes, specify diagnosis.

Are you or your partner(s) able to get pregnant?

If so, are you willing to not get yourself or partners pregnant throughout the duration of the study using highly effective contraception?

Do you have any other significant medical history or conditions, including surgeries/procedures?

Be sure to add the Disease, Diagnosis Date, and Medication/Procedure in the list above.

Drug History

Do you use any currently marijuana or THC containing products (including CBD products)?

Do you currently drink alcohol?

If yes, how many drinks do you average per day?

Do you have a history of alcohol abuse?

Do you take any medications, either prescription or over the counter? (ask specifically about inhalers and topical medications like creams)

Be sure to add the Medication or Supplement name, Indication, Dosage, Frequency, and Start Date

Have you been in any previous research trials?(Required)

If so, are you currently participating in any research trials?

​Update on COVID-19

To: Our Sponsors, CROs, Patients, and Employees

Colorado Questionnaires

Weight Loss & Type II Diabetes Questionnaire

Weight History

Medical History

Drug History

Update on COVID-19