Take Part!

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What is your name?* This field is required.
First Name
Last Name
2
What are your contact details?Based off the information you provide, Harvey Medical will contact you if you are a good fit for our upcoming studies. Our preferred method of contact is email, and we will never call you without first sending an email!
Please enter your email
Mobile (Optional)
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3
HIDDEN EMAIL
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Phone Number* This field is required.
5
Mobile Number
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What is your address?* This field is required.
Street Address
Street Address Line 2
City
County
Postcode
United Kingdom
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
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Benin
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Bosnia and Herzegovina
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Christmas Island
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
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Eritrea
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Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
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Greece
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Iran
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Israel
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Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
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Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
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Liberia
Libya
Liechtenstein
Lithuania
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Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Saint Vincent and the Grenadines
Samoa
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Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Slovenia
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South Ossetia
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eSwatini
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Taiwan
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Tanzania
Thailand
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Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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United Arab Emirates
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Uruguay
Uzbekistan
Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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What is your date of birth?* This field is required.
Date
Day
Month
Year
8
What is your occupation?
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Are you left or right handed?
Left
Right
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What is the highest level of education you have completed?
Please Select
Please Select
Higher Qualifications
Advanced Qualifications
Intermediate Qualifications
Foundation Qualifications
No Qualifications
11
What is your sex?* This field is required.A question about gender identity will follow later on in the questionnaire
Male
Female
Intersex
Prefer not to say
12
Is the gender you identify with the same as your sex registered at birth?This question is voluntary
Yes
No
Other
13
If applicable, what is the name of your parent/guardian/carer?
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Please answer these yes/no questions:* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
Do you smoke?
Do you wear glasses or contact lenses to correct your vision?
Do you use an inhaler?
Do you wear an ostomy bag (to collect urine or stool)?
Would you describe yourself as tech-savvy?
Do you smoke?
YesNo
YesNo
YesNo
YesNo
YesNo
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Do you self-inject to take any medication?* This field is required.
YESNO
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What kind of device do you use to self-inject medication to treat your health?• Pen devices can be an injection pen or auto-injector, where the pen is supplied already-loaded with medication and is activated by pushing down, or pressing a button. • Pre-filled syringes are disposable syringes that are supplied already-loaded with the medication (e.g., Humira®) • Syringe and vials are disposable syringes that requires the medication to be manually loaded. • On-body pumps are devices attached to the body to deliver medication (e.g., Omnipod®)
Yes, using a pen device
Yes, using a pre-filled syringe
Yes, using a syringe and vial
Yes, using an on-body pump
17
Do you experience any issues with dexterity?* This field is required.
YESNO
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How difficult would you find it to use your hands to...
Not difficult at all
A little difficult
Somewhat difficult
Very difficult
Nearly impossible to do
Impossible to do without help
Write a sentence with a pen or pencil?
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Cut meat on your plate with a knife & fork?
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Fasten buttons on your shirt/blouse?
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Turn a key in a lock?
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Write a sentence with a pen or pencil?
Cut meat on your plate with a knife & fork?
Fasten buttons on your shirt/blouse?
Turn a key in a lock?
Not difficult at all
Row 0, Column 0
A little difficult
Row 0, Column 1
Somewhat difficult
Row 0, Column 2
Very difficult
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Nearly impossible to do
Row 0, Column 4
Impossible to do without help
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Not difficult at all
Row 1, Column 0
A little difficult
Row 1, Column 1
Somewhat difficult
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Very difficult
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Nearly impossible to do
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Impossible to do without help
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Not difficult at all
Row 2, Column 0
A little difficult
Row 2, Column 1
Somewhat difficult
Row 2, Column 2
Very difficult
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Nearly impossible to do
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Impossible to do without help
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Not difficult at all
Row 3, Column 0
A little difficult
Row 3, Column 1
Somewhat difficult
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Very difficult
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Nearly impossible to do
Row 3, Column 4
Impossible to do without help
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Do you have any of the following medical conditions?Please check all that apply and press next
Allergy (Hayfever)
Allergy (Nuts)
Allergy (Peanuts)
Angina
Ankylosing Spondylitis
Arrhythmia (Irregular Heart Rhythm)
Asthma
COPD
Cancer
Cluster Headaches
Crohn's disease
Dexterity Issues
Diabetes (Type 1)
Diabetes (Type 2)
Eczema
Endometriosis
Fibromyalgia
Glaucoma
Growth Hormone Deficiency
HIV
Heart Failure
High Blood Pressure
Hyperthyroidism (Overactive Thyroid)
Hypothyroidism (Underactive Thyroid)
Idiopathic Pulmonary Fibrosis
Low Blood Pressure
Lupus
Macular Degeneration
Migraine
Multiple Sclerosis
Myocardial Infarction (Heart Attack)
Osteoarthritis
Psoriatic Arthritis
Pulmonary Arterial Hypertension
Pulmonary Hypertension
Rheumatoid Arthritis
Scleroderma
Sleep Apnea
Systemic Sclerosis
Ulcerative Colitis
20
Do you have any of the following medical conditions?Start typing and the
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Please specify any other medical conditions you have:Please click ADD MORE to list each medical condition as a new entry
22
Which medications do you currently take? (Optional)Please click ADD MORE to list each medication as a new entry
23
Please list the medication you are on below:
M1
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M2
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M3
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M4
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Are any of your close friends or family employed by any of the following:
Pharmaceutical manufacturer
Medical equipment manufacturer
Market research or advertising company
Medical office, clinic or hospital
None of the above
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Is there any other important personal information that we should be aware of?E.g., preferred contact method, preferred time to be contacted
29
I CONSENT TO THE PREVIOUS DATA PROTECTION TERMS* This field is required.Please confirm
Yes
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I CONSENT TO MY DETAILS BEING RETAINED FOR FUTURE STUDIES* This field is required.
Yes
No
31
IS THE INFORMATION YOU HAVE PROVIDED ACCURATE?* This field is required.Please confirm
Yes
32
WHERE DID YOU HEAR ABOUT US?* This field is required.
Facebook
Internet
Referral
Flyer
Instagram
Other source
33
HAVE YOU BEEN PROVIDED WITH A REFERRAL CODE? IF YES, PLEASE ADD BELOW* This field is required.
No referral code
Code C
Code J
Code A
Code V
Code F
Code P
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StudyLog
Please Select
Please Select
RA-003 (17-NOV-23)
VA-023
GK-040
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