BPSI: Triglycerides Pre-screener Form

Triglycerides Risk Factors Pre-screening
We are currently looking for participants living with elevated Triglycerides who otherwise are in general good health, free of daily medications.

You may have elevated triglycerides if you have the following risk factors:

Disclaimer:

All information submitted by subjects through this online pre-screener is housed in a HIPPA compliant environment and is kept strictly confidential. The information submitted will only be used by BPSI for the assessment of eligibility for studies that look for individuals who have elevated triglycerides

FOR RECRUITERS ONLY: Recruiter's Name
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Section 1: Demographics
18-2930-3940-4950-5960+
MaleFemaleOther
IndigenousCaucasianSouth AsianEast AsianAfrican/CaribbeanMiddle EasternOther
Input your BMI below*
If you don't know your BMI, calculate it clicking here.
BMI Calculation Value:
Section 2: Medical History
YesNoUnsure
YesNoUnsure
YesNoUnsure
Age OR BMI OR Section 2 Questions Calculation Value
Section 3: Lifestyle Factors
How often do you consume the following foods?
Foods high in refined carbohydrates (white bread, white rice, pastries, sugary cereals, pasta made with white flour)*

1

2

3

4

5

1 is Never, 5 is Daily
Calculation Value S3Q1:
Sugary drinks (soda, sweetened fruit juices, sweetened Iced tea, sports drinks, energy drinks)*

1

2

3

4

5

1 is Never, 5 is Daily
Calculation Value S3Q2:
Foods high in saturated fats (fried foods, processed meats, ribs, steaks, butter, cream, cheese, packaged snacks like chips and cookies)*

1

2

3

4

5

1 is Never, 5 is Daily
Calculation Value S3Q3:
Foods rich in omega-3 (fatty fish, flaxseeds, walnuts, seaweed, chia seeds)*

1

2

3

4

5

1 is Never, 5 is Daily
Calculation Value S3Q4:
Section 4 Calculation Value
NeverRarely (less than once a month)Occasionally (1-3 times a month)Frequently (1-3 times a week)Daily
Alcohol Check Calculation Value
Less than 1 hour1-2 hours3-4 hours5+ hours
Physical Activity Check Calculation Value
Final Calculation Value
Security Check
TrueFalse
PASSED?
Additional Comments
Should be Empty:

Triglycerides Risk Factors Pre-screening

Section 1: Demographics

Section 2: Medical History

Section 3: Lifestyle Factors