24PXCFP01- Papillex CIN1/2

1

Do we have your consent to ask you questions related to your lifestyle and medical history and to contact you regarding this study?If you answer NO, this survey will end.

YESNO

2

Name

First Name

Last Name

3

Email

example@example.com

4

Phone Number

Please enter a valid phone number.

5

Postal Code

6

Will you be able to commit to answer all requested online questionnaires to study completion?

YESNO

7

What was your assigned sex at birth?

Male

Female

8

Are you presently pregnant, planning to become pregnant or presently breastfeeding?

YESNO

9

Which form of birth control are you using?

I am no longer able to get pregnant (e.g., menopause (over 12 months), hysterectomy, bilateral oophorectomy, bilateral tubal ligation, complete endometrial ablation)

Hormone Contraceptives

Double barrier Method

Intrauterine Device

Non-heterosexual Lifestyle

Vasectomy of Partner (at least 6 months prior)

Abstinence

10

Please Enter Your Date of Birth

Date

11

What is your current height?

Height Number

Height Metric

12

What is your current weight?

Weight Number

Weight Metric

13

Have you been diagnosed with a CIN 1 (Cervical Intraepithelial Neoplasia 1) diagnosis from a pap smear in the last 18 months?

YESNO

14

Was the diagnosis confirmed through cytology?(Sample was sent to the lab by a practitioner and a report was received.)

YESNO

15

Will you be able to provide a copy of your pathology & cytology reports?

YESNO

16

Are you currently undergoing treatment for CIN or have had active treatment in the past 5 years?

YESNO

17

Would you be willing to undergo further Pap Smears and HPV test for study purposes?

YESNO

18

If required, will you be willing to have a colposcopy procedure? (Further sampling of cervical tissue using a lens to magnify the cervix and identify abnormal cells by a trained healthcare provider)

YESNO

19

Have you had a history of alcohol or illicit drug abuse, known drug dependence, or are seeking or have sought treatment for alcohol or substance abuse related disorders within the past 12 months?

YESNO

21

Have you had a major surgery in the past 3 months or plan to have surgery in the next 3 months?

YESNO

23

Did you select kidney issues because you have/had kidney stones?

YESNO

24

Have you been symptoms free for the past 6 months?

YESNO

25

Have you had a significant cardiovascular events in the past 6 months?

YESNO

26

Is your medical condition currently in stable condition (have been treated for at least 3 months with no changes in medications), that is, you are being followed by a physician and taking prescribed medication to control their condition?

YESNO

27

Are you taking medications to control your condition?

YESNO

28

How long have you been taking your medications

1-2 months

3-5 months

Over 6 months

Over 1 year

29

Have you had/been diagnosed with cancer in the past 5 years or are you currently receiving chemotherapy or radiation?This does not include skin cancer (basal cell carcinoma) that has been fully excised without chemotherapy or radiation.

YESNO

30

Are you currently using any of the prescribed medications?

Antifolate Medications (e.g., Methotrexate, Sulfasalazine, or phenytoin)

Immunosuppressive Therapies

32

Have you been taking these medications/supplements for at least 3 months?

YESNO

33

Are you currently taking other medications?

YESNO

34

Please list your medications.

35

Are you currently taking any other supplements?

YESNO

36

Please list below:

37

Have you donated in the past 30 days or are planning to donate blood in the next couple of months?

YESNO

38

Have you participated in a clinical trial within the last 30 days?

YESNO

40

Please describe where you heard about that study.

41

Please provide contact information for the person who referred you so we can thank them. Name & Email

42

Why did you decide to apply for participation in this study?

Interest in the topic being studied

Compensation being offered for participation

Have participated in clinical trial before.

Other

43

What was the other reason you decided to apply?

44

I consent to receiving communications from KGK Science Inc. and their third-party service providers (via electronic mail, electronic message, telecommunication, and automatic dialing-announcing device including the use of pre-recorded or synthesized voice messages). Your information will not be shared with and/or sold to external companies and is only used for communications with KGK Science.

YESNO