Brain Health Study

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Full Name* This field is required.
First Name
Last Name
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Please enter your age* This field is required.
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Hidden - Form Value
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Hidden - Age Pass/Fail
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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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Hidden - BMI Calculation
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Hidden - BMI Form Value
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Hidden - BMI Pass/Fail
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Are you a smoker, vaper or do you use any nicotine products?* This field is required.
Yes
No
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Hidden - Are you a smoker, vaper or do you use any nicotine products?* This field is required.
Yes
No
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Are you a vegetarian or vegan?* This field is required.
Yes
No
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Hidden - Are you a vegetarian or vegan?* This field is required.
Yes
No
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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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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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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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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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Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
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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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Phone Number* This field is required.
087/021
1234567
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Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
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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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Consent to mailing list - hidden* This field is required.
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Where did you hear about the study?* This field is required.
Instagram
Facebook
Cork Independent
96FM/C103
Email
Family/Friend
Previous Participant
Google Search
Website Ad
Flyer
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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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Score* This field is required.
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Reason* This field is required.
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Form Status* This field is required.
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