22KBCDF01

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

In relation to your current menstrual cycle, are you currently within 3 days of the end of menstruation, menstruating or will be beginning menstruation in the next 8-9 days?

YESNO

10

What is your current height?

Please enter a number

measurement

11

What is your current weight?

Please enter a number

measurement

12

Are you willing to travel to KGK Science in London, ON for four (4) visits in a row over the week of the study?

YESNO

13

Are you currently experiencing Urinary Tract Infection (UTI) symptoms (frequent, urgent, and/or painful urination, in complete voiding, pelvic and lower back pain and possible blood in urine)?

YESNO

14

Are you experiencing any signs of upper back and rib pain or tenderness, nausea or vomiting?

YESNO

15

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

16

Do you have a history of urological cancers (cancers of the male or female urinary system, bladder, renal (kidney) urethral?

YESNO

17

Have you been diagnosed with any of the following?

Anatomical Urinary Tract Abnormalities

Functions of Urinary Tract Abnormalities

Painful Bladder Syndrome

Neurogenic Bladder

Polycystic Kidney Disease

None

18

Do you use an indwelling catheter or need intermittent catherization?

YESNO

19

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

21

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

YESNO

22

Do you use recreational cannabis?

YESNO

23

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

24

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

YESNO

25

Do you have any allergies or food sensitivities?

YESNO

26

Please list your allergies or sensitivities.

27

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

YESNO

28

If yes, what time of surgery, and when.

30

If other, please indicated your medical condition.

31

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

32

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

YESNO

33

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

Antibiotics

Hormone Therapies

34

how long have you been on these medications?

35

Do you take any other prescription medication daily?

YESNO

36

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

37

Do you take D-Mannose?

YESNO

38

Are you currently eating/drinking the following?

Cranberry Juice

Cranberries

Craisins

Blueberries

39

Would you be willing to stop consuming these products during this study?

YESNO

40

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

YESNO

41

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

42

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

YESNO

43

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

YESNO

44

Have you participated in any other clinical research studies in the last 30 days?

YESNO

45

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

47

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.

48

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

49

If you pass screening we will need you see you as soon as possible so we can start the study and potentially start alleviating your symptoms. UTIs have a short window when you need to treatment. When are you available to come to clinic?

Date

50

What times would work for you 1st screening appointment? You are able to do virtual for 2nd and 3rd appointment.