Your details
By providing your information below, you are forming a contract with a A Picture of Health Ltd and agreeing to let us contact you about research projects and store your personal details.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Phone number
E-mail
example@example.com
Age
Job title / Student & course
If you are retired or unemployed please state this along with your previous job title
What is your highest level of education?
GCSE / O-Level / left school at 16 yrs
BTEC
NVQ Level 1
NVQ Level 2
NVQ Level 3
A-Levels
T-Levels
HNC
Bachelors / Masters / Uni Degree
Other
Are you male, female or prefer not to say?
Male
Female
Prefer not to say
Other
Do you regularly use or read written documents as part of your work?
Yes
No
How often do you use printed (hard copy) written documents?
Most days
Once or twice a week
Once or twice a month
How often do you use medicines (prescription and non-prescription)? Do not include birth control or vitamins
More than once a month
3 or 4 times a year
1 or 2 times a year or less
To ensure we recruit people without experience of certain medicines, please can you confirm the following: Have you taken any medicines or cared for anyone taking medicines for high-risk neuroblastoma (HRNB) in the last 6 months?
Yes
No
Have you taken any medicines or cared for anyone taking medicines for schizophrenia in the last 6 months?
Yes
No
Have you taken any medicines or cared for anyone taking medicines for arginase 1 deficiency (ARG1-D), also known as hyperargininemia, in the last 6 months?
Yes
No
Have you taken any medicines or cared for anyone taking medicines to relax the muscles when they have become dangerously over-stimulated, such as for the treatment of malignant hyperthermia, in the last 6 months?
Yes
No
Do you regularly care for a child under the age of 16 years?
Yes
No
If applicable: How old is the child/children you care for?
0-5 years
6-10 years
11-16 years
Not applicable
Have you taken part in similar research in the last 6 months?
Yes
No
Are you able to use Zoom if needed? We provide a link. You just need a computer, laptop or smart phone with Wi-Fi
Yes
No
Are you happy for us to store your details on our database and contact you in the future?
Yes
No
Which days and times would usually be convenient for a 30 to 40 minute Zoom or face to face study session?
Submit
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