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Tofu 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?
*
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
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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 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
Are you willing to replace one portion of red/processed med with tofu, daily for 8 weeks?
*
This field is required.
Tofu will be provided to you, free of charge
Yes
No
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16
Hidden - Are you willing to replace one portion of red/processed med with tofu, daily for 8 weeks?
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
*
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e.g. High blood pressure, high cholesterol, arthritis etc
Yes
No
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21
Please specify what medical conditions you have
*
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22
Are you currently taking any medications or supplements?
*
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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/intolerances?
*
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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 estimate your average food intake for the below foods as best you can. Please select an answer from each row
*
This field is required.
Never or less than once month
1-3 per month
Once a week
2-4 per week
5-6 per week
Once a day
2-3 a day
4-5 per day
6+ per day
Beef: roast, steak,mince, stew or casserole
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Beefburgers
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Row 1, Column 8
Pork: roast, chops, stew or slices
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Row 2, Column 7
Row 2, Column 8
Lamb/Mutton: roast, chops or stew
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Row 3, Column 7
Row 3, Column 8
Luncheon meat: chicken, turkey
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Row 4, Column 7
Row 4, Column 8
Bacon
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Row 5, Column 7
Row 5, Column 8
Ham
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Row 6, Column 7
Row 6, Column 8
Salami
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Row 7, Column 6
Row 7, Column 7
Row 7, Column 8
Corned beef, Spam, luncheon meats
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Row 8, Column 6
Row 8, Column 7
Row 8, Column 8
Sausages
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
Row 9, Column 6
Row 9, Column 7
Row 9, Column 8
Savoury pies, eg. Meat pie, pork pir, pasties, steak & kidney pie, sausage rollls
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Row 10, Column 5
Row 10, Column 6
Row 10, Column 7
Row 10, Column 8
Liver, liver pate, liver sausage
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Row 11, Column 5
Row 11, Column 6
Row 11, Column 7
Row 11, Column 8
Veal
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Row 12, Column 5
Row 12, Column 6
Row 12, Column 7
Row 12, Column 8
Venison
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Row 13, Column 5
Row 13, Column 6
Row 13, Column 7
Row 13, Column 8
Beef: roast, steak,mince, stew or casserole
Beefburgers
Pork: roast, chops, stew or slices
Lamb/Mutton: roast, chops or stew
Luncheon meat: chicken, turkey
Bacon
Ham
Salami
Corned beef, Spam, luncheon meats
Sausages
Savoury pies, eg. Meat pie, pork pir, pasties, steak & kidney pie, sausage rollls
Liver, liver pate, liver sausage
Veal
Venison
Never or less than once month
Row 0, Column 0
1-3 per month
Row 0, Column 1
Once a week
Row 0, Column 2
2-4 per week
Row 0, Column 3
5-6 per week
Row 0, Column 4
Once a day
Row 0, Column 5
2-3 a day
Row 0, Column 6
4-5 per day
Row 0, Column 7
6+ per day
Row 0, Column 8
Never or less than once month
Row 1, Column 0
1-3 per month
Row 1, Column 1
Once a week
Row 1, Column 2
2-4 per week
Row 1, Column 3
5-6 per week
Row 1, Column 4
Once a day
Row 1, Column 5
2-3 a day
Row 1, Column 6
4-5 per day
Row 1, Column 7
6+ per day
Row 1, Column 8
Never or less than once month
Row 2, Column 0
1-3 per month
Row 2, Column 1
Once a week
Row 2, Column 2
2-4 per week
Row 2, Column 3
5-6 per week
Row 2, Column 4
Once a day
Row 2, Column 5
2-3 a day
Row 2, Column 6
4-5 per day
Row 2, Column 7
6+ per day
Row 2, Column 8
Never or less than once month
Row 3, Column 0
1-3 per month
Row 3, Column 1
Once a week
Row 3, Column 2
2-4 per week
Row 3, Column 3
5-6 per week
Row 3, Column 4
Once a day
Row 3, Column 5
2-3 a day
Row 3, Column 6
4-5 per day
Row 3, Column 7
6+ per day
Row 3, Column 8
Never or less than once month
Row 4, Column 0
1-3 per month
Row 4, Column 1
Once a week
Row 4, Column 2
2-4 per week
Row 4, Column 3
5-6 per week
Row 4, Column 4
Once a day
Row 4, Column 5
2-3 a day
Row 4, Column 6
4-5 per day
Row 4, Column 7
6+ per day
Row 4, Column 8
Never or less than once month
Row 5, Column 0
1-3 per month
Row 5, Column 1
Once a week
Row 5, Column 2
2-4 per week
Row 5, Column 3
5-6 per week
Row 5, Column 4
Once a day
Row 5, Column 5
2-3 a day
Row 5, Column 6
4-5 per day
Row 5, Column 7
6+ per day
Row 5, Column 8
Never or less than once month
Row 6, Column 0
1-3 per month
Row 6, Column 1
Once a week
Row 6, Column 2
2-4 per week
Row 6, Column 3
5-6 per week
Row 6, Column 4
Once a day
Row 6, Column 5
2-3 a day
Row 6, Column 6
4-5 per day
Row 6, Column 7
6+ per day
Row 6, Column 8
Never or less than once month
Row 7, Column 0
1-3 per month
Row 7, Column 1
Once a week
Row 7, Column 2
2-4 per week
Row 7, Column 3
5-6 per week
Row 7, Column 4
Once a day
Row 7, Column 5
2-3 a day
Row 7, Column 6
4-5 per day
Row 7, Column 7
6+ per day
Row 7, Column 8
Never or less than once month
Row 8, Column 0
1-3 per month
Row 8, Column 1
Once a week
Row 8, Column 2
2-4 per week
Row 8, Column 3
5-6 per week
Row 8, Column 4
Once a day
Row 8, Column 5
2-3 a day
Row 8, Column 6
4-5 per day
Row 8, Column 7
6+ per day
Row 8, Column 8
Never or less than once month
Row 9, Column 0
1-3 per month
Row 9, Column 1
Once a week
Row 9, Column 2
2-4 per week
Row 9, Column 3
5-6 per week
Row 9, Column 4
Once a day
Row 9, Column 5
2-3 a day
Row 9, Column 6
4-5 per day
Row 9, Column 7
6+ per day
Row 9, Column 8
Never or less than once month
Row 10, Column 0
1-3 per month
Row 10, Column 1
Once a week
Row 10, Column 2
2-4 per week
Row 10, Column 3
5-6 per week
Row 10, Column 4
Once a day
Row 10, Column 5
2-3 a day
Row 10, Column 6
4-5 per day
Row 10, Column 7
6+ per day
Row 10, Column 8
Never or less than once month
Row 11, Column 0
1-3 per month
Row 11, Column 1
Once a week
Row 11, Column 2
2-4 per week
Row 11, Column 3
5-6 per week
Row 11, Column 4
Once a day
Row 11, Column 5
2-3 a day
Row 11, Column 6
4-5 per day
Row 11, Column 7
6+ per day
Row 11, Column 8
Never or less than once month
Row 12, Column 0
1-3 per month
Row 12, Column 1
Once a week
Row 12, Column 2
2-4 per week
Row 12, Column 3
5-6 per week
Row 12, Column 4
Once a day
Row 12, Column 5
2-3 a day
Row 12, Column 6
4-5 per day
Row 12, Column 7
6+ per day
Row 12, Column 8
Never or less than once month
Row 13, Column 0
1-3 per month
Row 13, Column 1
Once a week
Row 13, Column 2
2-4 per week
Row 13, Column 3
5-6 per week
Row 13, Column 4
Once a day
Row 13, Column 5
2-3 a day
Row 13, Column 6
4-5 per day
Row 13, Column 7
6+ per day
Row 13, Column 8
1
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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
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This field is required.
Please enter a valid phone number.
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32
Email
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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?
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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
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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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