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Vitamin B2 Questionnaire
Please fill out all required questions - this will help us determine your eligibility for the study. The questionnaire will take approx. 2 mins to complete
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HIPAA
Compliance
1
Full Name
*
This field is required.
First Name
Last Name
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2
Please select which clinic you will attend
*
This field is required.
Cork
Limerick
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3
Are you aged between 50-70?
*
This field is required.
This is inclusive of 50 & 70
Yes
No
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4
Hidden - Are you aged between 50-70?
Yes
No
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5
Please enter your weight and height
*
This field is required.
Note: You can toggle between imperial and metric using the arrow icon
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6
Hidden - BMI Calculation
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7
Hidden - BMI Form Value
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8
Hidden - BMI Pass/Fail
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9
Are you a smoker, vaper or do you use any nicotine products?
*
This field is required.
Yes
No
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10
Hidden - Are you a smoker, vaper or do you use any nicotine products?
*
This field is required.
Yes
No
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11
Are you a vegetarian or vegan?
*
This field is required.
Yes
No
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12
Hidden - Are you a vegetarian or vegan?
*
This field is required.
Yes
No
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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
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14
Hidden - 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
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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.
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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
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17
Hidden - Are you currently taking any medications or supplements?
*
This field is required.
Yes
No
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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
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19
Have you previously had any gastrointestinal surgery?
*
This field is required.
e.g appendectomy, gallbladder removal, hernia repair etc
Yes
No
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20
Hidden - Have you previously had any gastrointestinal surgery?
*
This field is required.
Yes
No
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21
Please specify the type of surgery, if you had any recovery issues & the year of the procedure
*
This field is required.
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22
Have you been diagnosed with any allergies or intolerances by a doctor or healthcare professional?
*
This field is required.
i.e. hayfever, food allergies, or intolerances like to gluten or lactose
Yes
No
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23
Hidden - Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?
*
This field is required.
Yes
No
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24
Please specify which allergies or intolerances you have
*
This field is required.
Note: with respect to food, please specify if it is an intolerance or allergy
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25
Phone Number
*
This field is required.
087/021
1234567
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26
Email
*
This field is required.
For contact regarding this study
example@example.com
Confirm Email
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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.
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28
Consent to mailing list - hidden
*
This field is required.
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29
Where did you hear about the study?
*
This field is required.
Instagram
Facebook
Classic Hits
96FM/C103
Limerick Leader
Echo
Email
Cork Independent
Family/Friend
Previous Participant
Google Search
Website Ad
Flyer
Other
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30
Consent to Privacy Notice
*
This field is required.
We need your explicit consent to process the personal data collected as part of this form in particular, health data. All personal data relevant to pre-screening for trials is processed in accordance with our Privacy Notice. You can withdraw consent by contacting us at dataprotectionofficer@atlantiatrials.com Do you consent to Atlantia Food Clinical Trials Ltd. processing the information you have provided in this form for the purpose of assessing your eligibility for this trial
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31
Score
*
This field is required.
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32
Reason
*
This field is required.
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33
Form Status
*
This field is required.
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