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Stress Study Questionnaire
Please fill out all required questions - this will help us determine your eligibility for the study. The questionnaire will take approx. 5 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?
*
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Female
Male
Other
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3
Date of Birth
*
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-
Date
Day
Month
Year
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4
Today's Date
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Date
Day
Month
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 pregnant, breastfeeding or planning a pregnancy?
*
This field is required.
Yes
No
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14
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
Yes
No
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15
Do you suffer from bouts of stress?
*
This field is required.
Yes
No
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16
Hidden - Do you suffer from bouts of stress?
Yes
No
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17
Do you suffer from any digestive issues such as coeliac disease, Crohn's, colitis, IBS, stomach or duodenal ulcers?
*
This field is required.
Yes
No
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18
Hidden - Do you suffer from any digestive issues such as coeliac disease, Crohn's, colitis, IBS, stomach or duodenal ulcers?
Yes
No
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19
Have you been diagnosed with any medical conditions?
*
This field is required.
e.g. High blood pressure, high cholesterol, celiac disease, etc
Yes
No
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20
Hidden - Have you been diagnosed with any (other) medical conditions
*
This field is required.
e.g. High blood pressure, high cholesterol, arthritis etc
Yes
No
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21
Please specify what medical conditions you have
*
This field is required.
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22
Are you currently taking any medications or supplements?
*
This field is required.
i.e. any medication or supplement e.g. daily blood pressure meds, diabetes, cholesterol, multivitamin, etc
Yes
No
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23
Hidden - Are you currently taking any medications or supplements?
*
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Yes
No
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24
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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25
Do you suffer from any allergies/intolerance?
*
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Yes
No
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26
Hidden - Do you suffer from any allergies/intolerance?
*
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Yes
No
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27
Please select the answer you feel is most appropriate for each question. Try to answer quickly without overthinking.
*
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Never
Almost Never
Sometimes
Fairly Often
Very Often
In the last month, how often have you been upset because of something that happened unexpectedly?
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
In the last month, how often have you felt that you were unable to control the important things in your life?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
In the last month, how often have you felt nervous and “stressed”?
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Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
In the last month, how often have you felt confident about your ability to handle your personal problems?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
In the last month, how often have you felt that things were going your way?
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Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
In the last month, how often have you found that you could not cope with all the things that you had to do?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
In the last month, how often have you been able to control irritations in your life?
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Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
In the last month, how often have you felt that you were on top of things?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
In the last month, how often have you been angered because of things that happened that were outside of your control?
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Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
In the last month, how often have you been upset because of something that happened unexpectedly?
In the last month, how often have you felt that you were unable to control the important things in your life?
In the last month, how often have you felt nervous and “stressed”?
In the last month, how often have you felt confident about your ability to handle your personal problems?
In the last month, how often have you felt that things were going your way?
In the last month, how often have you found that you could not cope with all the things that you had to do?
In the last month, how often have you been able to control irritations in your life?
In the last month, how often have you felt that you were on top of things?
In the last month, how often have you been angered because of things that happened that were outside of your control?
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
Never
Row 0, Column 0
Almost Never
Row 0, Column 1
Sometimes
Row 0, Column 2
Fairly Often
Row 0, Column 3
Very Often
Row 0, Column 4
Never
Row 1, Column 0
Almost Never
Row 1, Column 1
Sometimes
Row 1, Column 2
Fairly Often
Row 1, Column 3
Very Often
Row 1, Column 4
Never
Row 2, Column 0
Almost Never
Row 2, Column 1
Sometimes
Row 2, Column 2
Fairly Often
Row 2, Column 3
Very Often
Row 2, Column 4
Never
Row 3, Column 0
Almost Never
Row 3, Column 1
Sometimes
Row 3, Column 2
Fairly Often
Row 3, Column 3
Very Often
Row 3, Column 4
Never
Row 4, Column 0
Almost Never
Row 4, Column 1
Sometimes
Row 4, Column 2
Fairly Often
Row 4, Column 3
Very Often
Row 4, Column 4
Never
Row 5, Column 0
Almost Never
Row 5, Column 1
Sometimes
Row 5, Column 2
Fairly Often
Row 5, Column 3
Very Often
Row 5, Column 4
Never
Row 6, Column 0
Almost Never
Row 6, Column 1
Sometimes
Row 6, Column 2
Fairly Often
Row 6, Column 3
Very Often
Row 6, Column 4
Never
Row 7, Column 0
Almost Never
Row 7, Column 1
Sometimes
Row 7, Column 2
Fairly Often
Row 7, Column 3
Very Often
Row 7, Column 4
Never
Row 8, Column 0
Almost Never
Row 8, Column 1
Sometimes
Row 8, Column 2
Fairly Often
Row 8, Column 3
Very Often
Row 8, Column 4
Never
Row 9, Column 0
Almost Never
Row 9, Column 1
Sometimes
Row 9, Column 2
Fairly Often
Row 9, Column 3
Very Often
Row 9, Column 4
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28
Calculation
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29
Hidden - PHQ Form Value
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30
Hidden - PHQ Pass/Fail
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31
Phone Number
*
This field is required.
Please enter a valid phone number.
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32
Email
*
This field is required.
For contact regarding this study
example@example.com
Confirm Email
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33
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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34
Consent to mailing list - hidden
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35
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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36
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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37
Score
*
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38
Reason
*
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39
Form Status
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