Absorption Study

1

Full Name* This field is required.

First Name

Last Name

2

What is your sex?* This field is required.

Female

Male

Other

3

Hidden - What is your sex?* This field is required.

Female

Male

Other

4

What is your age?* This field is required.

5

Age - Form Value

6

Age - Pass/Fail

7

Please enter your weight and height* This field is required.Note: You can toggle between imperial and metric using the arrow icon

8

Hidden - BMI Calculation

9

Hidden - BMI Form Value

10

Hidden - BMI Pass/Fail

11

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

12

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

13

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.

14

Have you had any form of gastrointestinal surgery?* This field is required.

Yes

No

15

Hidden - Have you had any form of gastrointestinal surgery* This field is required.

Yes

No

16

Please specify what this surgery involved* This field is required.

17

Are you currently taking any medications or supplements?* This field is required.i.e. any medication or supplement including daily multivitamin, Vitamins D,C,E, probiotics, L-Theanine, etc.

Yes

No

18

Hidden - Are you currently taking any medications or supplements?* This field is required.

Yes

No

19

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

20

Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose

Yes

No

21

Hidden - Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.

Yes

No

22

Please specify which allergies or intolerances you have* This field is required.i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose

23

Are you currently following any specific diet?* This field is required.

Yes

No

24

Hidden - Are you currently on any specific diet?

Yes

No

25

Please specify the type of diet you are on* This field is required.

26

Do you smoke, vape or use any nicotine products?* This field is required.

Yes

No

27

Hidden - Do you smoke or use any nicotine products?

Yes

No

28

Have you previously had any issues with providing blood samples* This field is required.

Yes

No

29

Hidden - Have you previously had any issues with providing blood samples

Yes

No

31

Calculation

32

Hidden - Spermidine Form Value

33

Hidden - Spermidine Pass/Fail

34

Phone Number* This field is required.

Please enter a valid phone number.

35

Email* This field is required.For contact regarding this study

example@example.com

Confirm Email

36

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.

37

Consent to mailing list - hidden* This field is required.

39

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.

40

Score* This field is required.

41

Reason* This field is required.

42

Form Status* This field is required.