22GLCFG02-Diabetics

This survey will take no longer than 10 minutes of your time to complete and is intended to assess your eligibility for this KGK Science clinical trial. This clinical trial will investigate the safey and efficacy of GOLO for Life Plan and Release supplementation on weight management in overweight and obese adults with Type 2 Diabetes

We would like to ensure the data we collect can be verified by researchers and send updates on the study should you qualify to participate. All information recorded will be maintained with the strictest confidentiality except as required by law. For more information, please review our Privacy Policy.

Do we have your consent to ask you some questions related to your lifestyle and medical history and to contact you regarding this study?

YESNO

Name

First Name

Last Name

example@example.com

Phone Number

Please enter a valid phone number.

Please indicate your preferred contact method

Text

Phone

Any

Are you available to visit KGK Science in London, ON or Windsor, ON four (4) times over a period of approximately 6 months?

YESNO

What was your assigned sex at birth?

Male

Female

Are you presently pregnant, planning to become pregnant (during the study) or presently breastfeeding?

YESNO

Please Enter Your Date of Birth

Date

What is your Current HeightInches CM

Please enter a number

Metric

What is your Current Weight

Please enter a number

Metric

Has your body weight remained stable over the last 3 months? (i.e., you have not gained or lost more then 5kg/10lbs)

YESNO

Will you be willing to complete all diaries and questionnaires during this study as well as complete with dietary and exercise guidelines to the best of your ability?

YESNO

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

On average, how many standard alcoholic drinks do you consume per week?

None

Two or Less

3 to 5

6 to 9

10-14

15 or More

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

I currently smoke

No, I no longer smoke

I have never smoked

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

YESNO

Do you use recreational cannabis?

YESNO

How often do you use cannabis recreationally?

Daily (5-7+ times per week)

Reguarly (3-4x per week)

Weekly (1-2x per week)

Monthly (1-3x per month)

Occasionally (less then once per month)

How do you consume cannabis?

Drops

Edibles

Smoking

Cream

Other

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

YESNO

Have you been diagnosed with Diabetes?

YESNO

What type of diabetes do you have?

Diabetes 1

Diabetes 2

Do not know

Do you currently use insulin to manage your diabetes

YESNO

Are you allergic or sensitive to any of the following: (Please tick boxes to allergies)

Rhodiola

Inositiol

Berberine (Berberis vulgaris, Barberry)

Gardenia

Banaba (Lagerstoremia speciosa)

Salaretin (Salacia reticulata)

Apples

Rice

Do you have any other allergies or food sensitivities?

YESNO

Please List Your Allergies or Food Sensitivities

Have you had any major surgeries (including bariatric or weight loss surgeries) in the past 3 months, or do you have a major surgery planned during this study?

YESNO

If YES, what type of surgery?

Do you have any metal implants?

YESNO

Please list them and their location below:

Do you have a current or previous history of an eating disorder?

YESNO

Have you been diagnosed by a doctor of having obesity that has been induced by a metabolic or endocrinologic (hormone) disorder? (e.g., acromegaly, hypothalamic obesity)

Yes

Unsure

What was your diagnosis?

Have you ever been diagnosed with gout?

YESNO

When was your last gout flare up?

Date

Do you have history of or currently have any of the following medical conditions?

Thyroid-related Disorder

Chronic Kidney or Liver Disease

High Cholesterol

High Blood Pressure

Cardiac Issues

History of Gastrointestinal Issues (bariatric bypass surgery)

History of Cardiovascular Disease

History of Psychiatric Conditions

Metabolic Disease

Immune-compromised/Autoimmune Diseases

Chronic Inflammatory Disease

Other

If Other, please indicate your medical condition:

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

Did you tick kidney disease due to experiencing kidney stones?

YESNO

When was your last kidney stone?

Date

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

YESNO

Have you donated blood in the last 30 days?

YESNO

Please indicate which, if any, of the following prescription medications you take:

Weight loss medications

Appetite supressants

Glucose-Lowering medications (e.g., metformin)

Medications known to affect weight

Insulin

None of the above

If yes, how long have you been taking your medication for?

Do you use any other prescription medication regularly?

YESNO

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

Do you use any over-the-counter weight loss products? (e.g., Hydroxycut, thermogenic supplements)

YESNO

Do you take any supplements that are known to effect weight and/or fat loss (e.g., Omega 3 & 6, Flaxseed oil, green tea/coffee extracts)?

YESNO

How long have you been taking them for?

Would you be willing maintain the dose for the duration of the study?

YESNO

Do you use any over-the-counter medications or natural health products regularly?

YESNO

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

Would you be willing to stop taking these over-the-counter medications or supplements listed previously during the study or prior to study visits (run-in period) as required?

YESNO

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

YESNO

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

YESNO

Please enter the date your participation in the clinical trial ended.

Date

How did you hear about this study

Facebook/Instagram

Website

Google

Radio

Magazine

Someone Referred me

Other

Please Provide Name of Person who Referred YouWe have a referral program and we would like to thank them :)

First Name

Last Name

Why did you decide to apply for this study?

Interest in topic being studied

Compensation being offered

Have participated in other clinical trials

Other

If Other, please describe

Which site would you prefer to attend?

London, ON

Windsor, ON

I consent to receiving communication from KGK Science Inc. and their third-party service providers via electronic mail, electronic message, telecommunications and automatic dialing-announcing devices including the use of pre-recorded or synthesized voice messages.

Clear