Enoch 22ESPRSZ03

1
Do we have your consent to ask you some questions related to your lifestyle, medical history and to contact you regarding this study? (If you answer no, this survey will end.)
YESNO
2
Name
First Name
Last Name
3
Email
example@example.com
4
Phone Number
Please enter a valid phone number.
5
Please indicate your preferred contact method:
Email
Text
Phone
6
Are you available to visit KGK Science in London, ON 5 times over a period of approximately 4 weeks?
YESNO
7
What was you assigned sex at birth?
Male
Female
8
Are you presently pregnant, planning to become pregnant or presently breastfeeding?
YESNO
9
Are you currently using a method of birth control?
YESNO
10
Please indicate what form of birth control you are using? (i.e., prescription birth control, IUD, Menopause, Husband had vasectomy, etc.)
11
Please Enter Your Date of Birth
Date
Year
Month
Day
12
Do you have a history of alcohol or illicit drug abuse, known drug dependence, or are seeking or have sought treatment for alcohol or substance abuse related disorders within the past 12 months?
YESNO
13
On average, how many standard alcoholic drinks do you consume per week?
None
Two or Less
3-5
6-9
10-14
15 or more
14
How often do you consume alcohol per week?
Once
Twice
3x
4x
5+
15
Do you use tobacco products? (e.g., cigarettes, vapes, e-cigarettes)
YESNO
16
Do you have a prescription for the use of cannabis products?
YESNO
17
Do you use recreational cannabis?
YESNO
18
How often do you use cannabis recreationally?
Daily or 5-7+ times a week
Regularly or 3-4 times a week
Weekly or 1-2 times a week
Monthly or 1-2 times per month
Occasionally/less than once per moth
19
Would you be willing to refrain from using cannabis for the duration of the study?
YESNO
20
Have you been diagnosed with cancer?
YESNO
21
Is your cancer considered to be CNS Malignance (e.g., brain or spine)?
YESNO
22
Is your cancer breast cancer?
YESNO
23
Is your breast cancer estrogen-receptor positive?
Yes
No
Unknown
24
Will you be able to provide documentation to indicate your breast cancer is NOT estrogen-positive?
YESNO
25
Will you be able to find out from your doctor what type of breast cancer you have?
YESNO
26
Do you have any allergies or food sensitivities?
YESNO
27
Have you been experiencing cancer-related fatigue (Cancer Fatigue is defined as a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and recent activity and interferes with usual functioning)
YESNO
28
When did you complete your last cancer treatment? (Treatment being radiation, chemotherapy, immunotherapy, target therapy, surgery)
Date
Year
Month
Day
29
Are you scheduled for any further cancer treatment?
YESNO
30
When is your next cancer treatment schedules for?
Date
Year
Month
Day
31
Please describe the treatment of your upcoming treatment plan. (i.e., radiation, chemotherapy, immunotherapy, target therapy, surgery)
32
Please list your allergies or sensitivities
33
Have you had any major surgeries in the past 3 months, or do you have a major surgery planned during the course of the study?
YESNO
34
If Yes, what type of surgery?
35
Do you have a history of/or currently have any of the following medical conditions?
Diabetes Type 1/Type 2
Depression/Psychiatric Disorder
Insomnia/Sleep Disorders
Diagnosed Chronic Pain (non-cancer related)
Thyroid-related Disorder
Chronic Kidney Disease
High Cholesterol
High Triglycerides
High Blood Pressure
Tachycardia/Heart Rhythm Issues
History of Gastroinestinal Disease or issues (bariatric bypass surgery for example)
Hepatic or Renal Disease
History of Cardiovascular Disease
Metabolic Disease
Immune-compromised/Autoimmune Disease
Other
36
If other, please indicate your medical condition.
37
Is your medical condition currently in stable condition, that is, are you being followed by a physician and taking prescribed medication to control your condition?
YESNO
38
Did you tick kidney disease due to experiencing Kidney Stones?
YESNO
39
When was your last kidney stone?
Date
Year
Month
Day
40
Please use this space to provide more information about your "Other" medical condition
41
Have you had a significant cardiac event in the past 6 months?
YESNO
42
Have you donated blood in the last 30 days?
YESNO
43
Please indicate which, if any, of the following prescription medication you take:
Anti-depressants/Anti-anxiety
Anti-Coagulants (blood thinners e.g., warfarin, heparin)
Cardiovascular (heart) medications (e.g., Digoxin, Calcium channel blockers, cholesterol (statins))
Beta Blockers
Antihistamines
Antimetics
Monoamine Oxidase Inhibitors (MAOIs. eg. Nardil, Parnate, Ernsame, Marplan)
Narcotics
Stimulants (mehylphenidate, mondafinil, adderall, ritalin, concerta, focalin, provigil, sparlon)
None of the above
44
Do you use any other prescription medications daily?
YESNO
45
Please list your prescription medication, dose, frequency and the reason for use:
46
Do you use any over-the-counter medications and/or supplements?
YESNO
47
Would you be willing to stop taking these over-the-counter medication or supplements listed previously during the study or prior to study visits as required?
YESNO
48
Will you be willing to maintain current lifestyle habits throughout the study, including diet, medications, supplements, sleep, exercise and avoid taking any new supplements?
YESNO
49
Have you participated in a clinic trial within the last 30 days?
YESNO
50
Please enter date the clinic trial participated ended. (Or is due to end)
Date
Year
Month
Day
51
How did you hear about this study?
Facebook
Instagram
Email
Website
Radio
Google
Flyers
Reddit
Flyers
YouTube
Tictoc
Someone referred me
Other
52
Please list who referred you so we can thank them.
53
Please List Other
54
Why did you decide to apply for participation in this study?
Interest in the Topic Being Studied
Compensation being offered for Paticipation
Have participated in clinic trials before
Other
55
Please let us know why you decided to participate.
56
I consent to receiving communication from KGK Science Inc, and their third-party service providers via electronic message, telecommunication, and automatic dialing-announcing device including the use of pre-recorded or synthesize voice messages.
Yes I do
Should be Empty: