22ENRCL01-Ethical Naturals

1

Do we have your consent to ask you some questions related to your lifestyles and 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:

Phone

Email

Either

6

What was your assigned sex at birth?

Male

Female

7

Are you presently pregnant, planning on becoming pregnant or present breastfeeding?

YESNO

8

Please enter your date of birth.

Date

9

Have you graduated high school or equivalent and have basic computer skills?

YESNO

10

Does your employment require you to do shift work?

YESNO

11

Please describe your typical shifts and frequency if it changes. (For example, 12am-8am every 2 weeks)

12

Have you travelled across one (1) or more time zones in the last 3 weeks or are planning to do so in the next 2 months?

YESNO

13

Have you had 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

14

Are you willing to avoid high caffeine consumption during this study?(No more than 2 cups per day of coffee/tea/energy drinks)

YESNO

15

Are you willing to refrain from vigorous (increased heart rate, sweating, out of breath) physical activity 24 hours before study visits?

YESNO

18

Do you use tobacco products or nicotine containing products (e.g., cigarettes, vapes, e-cigarettes)?

Yes

No

I have never smoked

19

When was the last time you used tobacco and/or nicotine containing products?

Date

20

Do you have a prescription for the use of cannabis products?

YESNO

21

Do you use recreational cannabis?

YESNO

22

How often do you use cannabis recreationally?

Daily or 5-7+ times per week

Regularly or 3-4 times per week

Weekly or 1-2 times per week

Monthly or 1-3 times per month

Occasionally/less than once per month

23

Would you be willing to refrain from using cannabis for the duration of the study?

YESNO

24

Do you have a stress or sleep disorder?

YESNO

25

Do you experience colour-blindness?

YESNO

26

Please describe you experience with colour-blindness.(i.e., I see no colour, certain colours etc)

27

Do you have any allergies or food sensitivities?

YESNO

28

Please list your allergies or sensitivities.

29

Have you had any major surgery in the past 3 months, or do you have major surgery planned during the study?

YESNO

30

If yes, what time of surgery, and when.

32

If other, please indicated your medical condition.

33

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

34

Did you tick kidney disease due to experiencing kidney stones?

YESNO

35

When was your last kidney stone?

36

Have you had a significant cardiac event in the past 6 month?

YESNO

37

Have you had a diagnosed of cancer within the past 5 years or are you currently receiving chemotherapy or radiation treatment? This does not include skin cancer (basil cell carcinoma) that has been fully excised without chemotherapy or radiation.

YESNO

38

Have you donated blood in the last 30 days or plan to during the study?

YESNO

40

Do you take any other prescription medication daily?

YESNO

41

Please list your prescription medications, dose, frequency and the reason for use:

43

These supplements may interfere with the study results, would you be willing to abstain from taking them during the 6 weeks of the study?

YESNO

44

Do you use any other over-the-counter medications and/or supplements?

YESNO

45

Please list your over-the-counter medications and/or supplements.

46

Will you be willing to maintain your current lifestyle habits throughout the study, including diet, medications, supplements, sleep schedule, exercise and avoid taking any new supplements?

YESNO

47

Have you participated in a clinical trial within the last 30 days.

YESNO

48

Please enter the date the clinical trial you participated in ended (DD/MM/YY)

50

Please provide name and phone number or email so we can thank them!KGK Science has a referral program, thank you for being a Health Hero.

51

Why did you decide to apply for participation in this study?

Interest in topic being studied

Compensation being offered for participation

I have participated in clinical trial before

Other

52

If other, please let us know why?

53

YESNO