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General health problems
      Yes No

Do your know your dress/pant size? If so,  please select (1= x-small to  7= xx-large)

Have you ever tried recreational drugs?

If you have tried recreation drugs, when last did you taker recreational drugs?

How many cigarettes do you smoke a day? (or are exposed to)

When are you planning on having your next child?

Have you ever participated in a clinical trial before?

When was the last time you went to a doctor, hospital or clinic?

Is your time/work flexible enough, so you can attend multiple clinic visits?

I would be interested in participating in research that involves (please select all that apply):

For the information above to be stored on a log of potential adult volunteers (Managed by UCT/MRC Collaborating Centre for Optimising Antimalarial Therapy , Obsevatory, Cape Town)

I am also willing to be contacted by delegated members of the UCT/MRC Collaborating Centre for Optimising Antimalarial Therapy or the clinical research centre to update this information