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Stress Study Questionnaire
Please fill out all required questions - this will help us determine your eligibility for the study. The questionnaire will take approx. 4 mins to complete
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1
Full Name
*
This field is required.
First Name
Last Name
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2
What is your age?
*
This field is required.
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3
Age - Form Value
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4
Age - Pass/Fail
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5
Are you pregnant, breastfeeding or planning a pregnancy?
*
This field is required.
Yes
No
N/A - Male
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6
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
Yes
No
N/A - Male
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7
Have you been involved in any in-person public speaking or presented to large groups (more than 15 people) in the last 12 months?
*
This field is required.
Yes
No
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8
Please specify how many times you have done public speaking/presenting in the last 12 months
*
This field is required.
1
2
3
4
5+
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9
Hidden - Please specify how many times you have done public speaking/presenting in the last 12 months
1
2
3
4
5+
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10
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
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11
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
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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.
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13
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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14
Hidden - Are you currently taking any medications or supplements?
*
This field is required.
Yes
No
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15
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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16
Please select the most appropriate answer based on your
feelings in the last month
*
This field is required.
Never
Almost Never
Sometimes
Fairly Often
Very Often
How often have you been upset because of something that happened unexpectedly?
How often have you felt that you were unable to control the important things in your life?
How often have you felt nervous and “stressed”?
How often have you felt confident about your ability to handle your personal problems?
How often have you felt that things were going your way?
How often have you found that you could not cope with all the things that you had to do?
How often have you been able to control irritations in your life?
How often have you felt that you were on top of things?
How often have you been angered because of things that happened that were outside of your control?
How often have you felt difficulties were piling up so high that you could not overcome them?
How often have you been upset because of something that happened unexpectedly?
How often have you felt that you were unable to control the important things in your life?
How often have you felt nervous and “stressed”?
How often have you felt confident about your ability to handle your personal problems?
How often have you felt that things were going your way?
How often have you found that you could not cope with all the things that you had to do?
How often have you been able to control irritations in your life?
How often have you felt that you were on top of things?
How often have you been angered because of things that happened that were outside of your control?
How often have you felt difficulties were piling up so high that you could not overcome them?
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
Never
Almost Never
Sometimes
Fairly Often
Very Often
1
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17
Hidden - Stress Calculation
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18
Hidden - Stress Form Value
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19
Hidden - Stress Pass/Fail
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20
Phone Number
*
This field is required.
087/021
1234567
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21
Email
*
This field is required.
For contact regarding this study
example@example.com
Confirm Email
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22
Where did you hear about the study?
*
This field is required.
Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
UCC
MTU
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23
Would you like to be subscribed to Atlantia's database?
*
This field is required.
If you elect to be part of our database, you may be notified of future studies that Atlantia is undertaking that may be of interest to you. All communications to our database are undertaken in accordance with our Privacy Notice available at: https://atlantiaclinicaltrials.com/privacy-notice.
Yes, Subscribe Me
No, thank you.
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24
Consent to mailing list - hidden
*
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25
Consent to Privacy Notice
*
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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 for the purpose of assessing your eligibility for this trial
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26
Score
*
This field is required.
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27
Reason
*
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28
Form Status
*
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