Vitamin C Study

1
Full Name* This field is required.
First Name
Last Name
2
Are you aged between 50-70?* This field is required.This is inclusive of 50 & 70
Yes
No
3
Hidden - Are you aged between 50-70?
Yes
No
4
Please select your sex
Male
Female
5
Are you post/peri-menopausal?
Yes
No
6
Hidden - Are you post/peri-menopausal?
Yes
No
7
Please enter your weight and height* This field is required.Note: You can toggle between imperial and metric using the arrow icon
8
Hidden - BMI Calculation
9
Hidden - BMI Form Value
10
Hidden - BMI Pass/Fail
11
Are you a smoker, vaper or do you use any nicotine products?* This field is required.
Yes
No
12
Hidden - Are you a smoker, vaper or do you use any nicotine products?* This field is required.
Yes
No
13
Have you been diagnosed with any medical conditions?* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
14
Hidden - Have you been diagnosed with any (other) medical conditions* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
15
Please specify what medical conditions you have been diagnosed with* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc.
16
Are you currently taking any medications or supplements?* This field is required.e.g blood pressure/cholesterol meds, multivitamins, probiotics or prebiotics
Yes
No
17
Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
18
Please specify what medications or supplements you are currently taking* This field is required.If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure
19
Have you previously had any gastrointestinal surgery?* This field is required.e.g appendectomy, gallbladder removal, hernia repair etc
Yes
No
20
Hidden - Have you previously had any gastrointestinal surgery?* This field is required.
Yes
No
21
Please specify the type of surgery, if you had any recovery issues & the year of the procedure* This field is required.
22
Have you been diagnosed with any allergies or intolerances by a doctor or healthcare professional?* This field is required.i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose
Yes
No
23
Hidden - Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.
Yes
No
24
Please specify which allergies or intolerances you have* This field is required.i.e. seasonal, medication, or food allergies, or intolerances to gluten, lactose
25
Phone Number* This field is required.
087/021
1234567
26
Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
27
Would you like to be subscribed to Atlantia's database?* This field is required.Subscribing to this allows us to contact you occasionally via email with study updates or new studies
Yes, Subscribe Me
No, thank you.
28
Consent to mailing list - hidden* This field is required.
29
Where did you hear about the study?* This field is required.
Instagram
Facebook
Yaycork
Cork Independent
96FM/C103
Email
Family/Friend
Previous Participant
Google Search
Website Ad
Flyer
30
Consent to Privacy Notice* This field is required.You must agree to our Privacy Notice in order for us to process your data to determine your eligibility for the study
31
Score* This field is required.
32
Reason* This field is required.
33
Form Status* This field is required.
Should be Empty: