Multivitamin Study

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Full Name* This field is required.
First Name
Last Name
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What is your sex?* This field is required.
Female
Male
Other
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Hidden - What is your sex?
Female
Male
Other
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Date of Birth* This field is required.
Date
Day
Month
Year
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Today's Date
Date
Day
Month
Year
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Hidden - Days Calculation
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Hidden - Age Calculation
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Hidden - Age Form Value
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Hidden - Age Pass/Fail
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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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Hidden - BMI Calculation
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Hidden - BMI Form Value
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Hidden - BMI Pass/Fail
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Are you pregnant, breastfeeding or planning a pregnancy?* This field is required.
Yes
No
15
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
Yes
No
16
Have you had a regular menstrual cycle in the last 12 months?* This field is required.
Yes
No
17
Hidden - Have you had a regular menstrual cycle in the last 12 months?
Yes
No
18
Are you currently using any form of contraception?* This field is required.
Yes
No
19
Please specify what form of contraception?* This field is required.
Oral Contraceptioon (The Pill)
IUD (Coil)
Implant (Bar)
Contraception Injection
Contraception Patch
Vaginal Ring
Condom
Other
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Hidden - Please specify what form of contraception?
Oral Contraceptioon (The Pill)
IUD (Coil)
Implant (Bar)
Contraception Injection
Contraception Patch
Vaginal Ring
Condom
Other
21
Are you a smoker?* This field is required.
Yes
No
22
Hidden - Are you a smoker?* This field is required.
Yes
No
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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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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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Please specify what medical conditions you have* This field is required.
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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
27
Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
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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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Do you suffer from any allergies/intolerances?* This field is required.
Yes
No
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Hidden - Do you suffer from any allergies/intolerance?* This field is required.
Yes
No
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Hidden - PHQ Form Value
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Hidden - PHQ Pass/Fail
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Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
35
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.
36
Consent to mailing list - hidden* This field is required.
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Where did you hear about the study?* This field is required.
Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
Other
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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 Data Protection Statement available on our Data Protection Page. You can withdraw your consent at any time by contacting us at dataprotectionofficer@atlantiatrials.com Do you consent to Atlantia Clinical Trials processing the personal data you have provided in this form for the purpose of assessing your eligibility for this trial?
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Score* This field is required.
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Reason* This field is required.
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Form Status* This field is required.
Should be Empty: