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Metabolic Syndrome 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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HIPAA
Compliance
1
Full Name
*
This field is required.
First Name
Last Name
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2
What is your sex?
*
This field is required.
Female
Male
Other
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3
Date of Birth
*
This field is required.
-
Date
Month
Day
Year
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4
Today's Date
-
Date
Month
Day
Year
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5
Hidden - Days Calculation
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6
Hidden - Age Calculation
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7
Hidden - Age Form Value
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8
Hidden - Age Pass/Fail
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9
Please enter your weight and height
*
This field is required.
Note: You can toggle between imperial and metric using the arrow icon
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10
Hidden - BMI Calculation
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11
Hidden - BMI Form Value
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12
Hidden - BMI Pass/Fail
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13
Are you a smoker, vaper or do you use any nicotine products?
*
This field is required.
Yes
No
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14
Hidden - Are you a smoker, vaper or do you use any nicotine products?
*
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Yes
No
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15
Which of the following best describes your current blood sugar status?
*
This field is required.
Type I Diabetes
Type II, medicated
Type II Diabetes, unmedicated, treated with diet & exercise
Type II Diabetes, unmedicated
Pre-Diabetes
My blood sugar levels are normal
I do not know what my blood sugar levels are
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16
Hidden - Which of the following best describes your current blood sugar status?
Type I Diabetes
Type II, medicated
Type II Diabetes, unmedicated, treated with diet & exercise
Type II Diabetes, unmedicated
Pre-Diabetes
My blood sugar levels are normal
I do not know what my blood sugar levels are
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17
Please select the most appropriate answers from the following table with regards to your health:
*
This field is required.
On medication
Diagnosed but unmedicated
Unsure
Do not have
Raised Blood Pressure
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Raised Cholesterol
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Raised Blood Pressure
Raised Cholesterol
On medication
Row 0, Column 0
Diagnosed but unmedicated
Row 0, Column 1
Unsure
Row 0, Column 2
Do not have
Row 0, Column 3
On medication
Row 1, Column 0
Diagnosed but unmedicated
Row 1, Column 1
Unsure
Row 1, Column 2
Do not have
Row 1, Column 3
1
of 2
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18
Have you been diagnosed with any (other) medical conditions?
*
This field is required.
e.g. Celiac disease, Parkinson's, Gout
Yes
No
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19
Hidden - Have you been diagnosed with any medical conditions
*
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e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
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20
Please specify what medical conditions you have
*
This field is required.
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21
Are you currently taking any (other) medications or supplements?
*
This field is required.
i.e. any medication or supplement e.g. thyroid meds, stomach acid meds, probiotics, multivitamin, etc
Yes
No
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22
Hidden - Are you currently taking any medications or supplements?
*
This field is required.
Yes
No
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23
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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24
Phone Number
*
This field is required.
Please enter a valid phone number.
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25
Email
*
This field is required.
For contact regarding this study
example@example.com
Confirm Email
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26
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.
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27
Consent to mailing list - hidden
*
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28
Where did you hear about the study?
*
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Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
Other
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29
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.
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30
Score
*
This field is required.
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31
Reason
*
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32
Form Status
*
This field is required.
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