Nutrition

1
Full Name* This field is required.
First Name
Last Name
2
Are you aged between 18-65?* This field is required.
Yes
No
3
Hidden - Are you aged between 18-65?
Yes
No
4
Please enter your weight and height* This field is required.Note: You can toggle between imperial and metric using the arrow icon
5
Hidden - BMI Calculation
6
Hidden - BMI Form Value
7
Hidden - BMI Pass/Fail
8
Are you pregnant, planning a pregnancy, or breastfeeding?* This field is required.
Yes
No
N/A - Male volunteer
9
Hidden - Are you pregnant, planning a pregnancy or breastfeeding?* This field is required.
Yes
No
N/A - Male volunteer
10
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
11
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
12
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.
13
Have you had any form of gastrointestinal surgery?* This field is required.
Yes
No
14
Hidden - Have you had any form of gastrointestinal surgery* This field is required.
Yes
No
15
Please specify what this surgery involved* This field is required.
16
Are you currently taking any medications or supplements?* This field is required.i.e. any medication or supplement including daily multivitamin, Vitamins D,C,E, probiotics, L-Theanine, etc.
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 been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose
Yes
No
20
Hidden - Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.
Yes
No
21
Please specify which allergies or intolerances you have* This field is required.i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose
22
Are you willing to consume a vegan diet exclusively for 4 weeks?* This field is required.
Yes
No
23
Hidden - Are you willing to consume a vegan diet exclusively for 4 weeks?* This field is required.
Yes
No
24
Are you currently on any specific diet?* This field is required.
Yes
No
25
Hidden - Are you currently on any specific diet?
Yes
No
26
Please specify the type of diet you are on* This field is required.
27
Please select the average daily serving(s) that you would consume of the beverages listed below* This field is required.
0
1
2
3
4
5+
Coffee
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Tea (non-herbal)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Energy Drink (16oz)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Coffee
Tea (non-herbal)
Energy Drink (16oz)
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
5+
Row 0, Column 5
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
5+
Row 1, Column 5
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
5+
Row 2, Column 5
1 of 3
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Hidden - Caffeine Calculation
29
Hidden - Caffeine Form Value
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Hidden - Caffeine Pass/Fail
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Do you smoke or use any nicotine products?* This field is required.
Yes
No
32
Hidden - Do you smoke or use any nicotine products?
Yes
No
33
Phone Number* This field is required.
Please enter a valid phone number.
34
Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
35
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.
36
Consent to mailing list - hidden* This field is required.
37
Where did you hear about the study?* This field is required.
Instagram
Facebook
My Doctor
Previous Participant
Email
Friend/Family Member
Google Search
Website Ad
Flyer
Other
38
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.
39
Score* This field is required.
40
Reason* This field is required.
41
Form Status* This field is required.
Should be Empty: