Research Consent Application

At Warrington & Halton Hospitals NHS Foundation Trust many of our patients take part in research studies helping to develop new treatments and cures for a wide variety of health conditions.

Your Pathway to Research is an initiative created to establish a register of people interested in taking part in health research and who agree to be contacted by members of the research team about current or future research projects.

As a first step, we are creating a register of people who would be willing for research staff to contact them to ask if they would like to take part in current or future research projects that interest them. You may have been asked by your consultant already or if you are interested, you can ask them

At this stage we’re not asking you to agree to any particular study. By using your records, researchers can check if you might be suitable for a specific research project based on different aspects of your health, for example, your symptoms or your medication. Only research staff working for Warrington and Halton NHS Foundation Trust (e.g. research nurses, midwives or Consultants) will be able to use the information in the register.

Do you have or suffer from any of the following conditions:
Stomach and Bowel problems Yes No
If yes please give a brief description
Liver and Kidneys problems Yes No
If yes please give a brief description
Cancer Yes No
If yes please give a brief description
Heart and lung problems Yes No
If yes please give a brief description
High blood pressure Yes No
If yes please give a brief description
Diabetes Yes No
If yes type 1 or type 2
Joint conditions Yes No
If yes please give a brief description
Nervous system problems (i.e epilepsy) Yes No
If yes please give a brief description
Are you pregnant? Yes No
Have you had a miscarriage? Yes No
Are you hoping to get pregnant in the next 12 months? Yes No
Have you ever had a stroke or TIA (mini stroke)? Yes No
Are you taking any medicines? Yes No
Please list
Any major operations recently? Yes No
If yes please give a brief description
Please use the space below to give any information about yourself you feel may be useful for future research
Would you be happy to be contacted if any research became available into any illnesses you have? Yes No
If you’ve answered yes to any of these questions we would like to ask a few questions.
Fields marked with a red asterisk * are required
Contact Details
*
*
*
*
How would you prefer to be sent information about the hospitals and membership? Post E-Mail
About You
The data you give will help us see if our Membership is representative of our local communities.
Sex: Male Female
- -
What is your ethnic group? Please tick one of these boxes as appropriate.
White:

British

Irish

Other
 
Mixed:

White & Black Caribbean

White & Black African

White & Asian

Other
Black:

Caribbean

African

Other
 
Asian:

Indian

Pakistani

Bangladeshi

Other
Other Ethnic group:

Chinese

Other

I'd Rather Not Say
 
Declaration
*   I consent to my information being stored on the Warrington and Halton Hospitals NHS Foundation Trust’s research database. I am happy for the Research Team to contact me if they have any further questions or have further studies that might be of interest to me.
Thank you for taking the time to register. Your details will be held on a confidential database in accordance with the Data Protection Act 1998.