General Participant Information
Full legal Name
*
First Name
Last Name
Gender
*
Please Select
Female
Male
Non-binary
Transgender woman
Transgender man
Gender non-conforming
Prefer to self-describe (please specify)
Prefer not to answer
If you selected 'Prefer to self-describe', please specify your gender identity
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Ethnicity / Race
Please Select
White/Caucasian
Black/African
Hispanic/Latino
Asian
Native American
Mixed Heritage Background
Height (cm's)
*
Weight (kg's)
*
Exercise
Please Select
None
1–2 days per week
3–4 days per week
5 or more days per week
Alcohol Consumption
Please Select
Never or rarely
Socially (occasionally)
Regularly (weekly)
Daily or heavy use
Do you Smoke
Please Select
Non-smoker (never smoked)
Former smoker (quit more than 12 months ago)
Former smoker (quit less than 12 months ago)
Current smoker – light (1–5 cigarettes/day)
Current smoker – moderate (6–15 cigarettes/day)
Current smoker – heavy (16+ cigarettes/day)
Vaper / e-cigarette user
Occasional smoker (less than weekly)
Prefer not to answer
If you smoke or vape, how many years have you been smoking/vaping?
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Participant Medical History
Known Medical Conditions (Please check all that apply)
Hypertension (high blood pressure)
Diabetes mellitus (Type 1 or Type 2)
Cardiovascular disease (e.g., heart attack, coronary artery disease, etc.)
Stroke or transient ischemic attack (TIA)
Chronic lung disease (e.g., asthma, COPD, etc.)
Kidney disease
Liver disease
Autoimmune disorders (e.g., Thyroid, rheumatoid arthritis, lupus, etc.)
Neurologic conditions (e.g., epilepsy, multiple sclerosis, etc.)
Gastrointestinal diseases (e.g., Crohn’s disease, ulcerative colitis, etc.)
Cancer (specify type and date of diagnosis, etc.)
Reproductive and hormonal conditions (e.g., PCOS, Endometriosis, etc.)
Mental health conditions (e.g., Depression, PTSD, etc.)
HIV/AIDS or other immunodeficiency
Other chronic conditions (please describe)
None of the above
Other
Please describe your health condition and the year of diagnosis
Please include: condition name, year of diagnosis, current severity (mild/moderate/severe), and current management approach.
Please list any surgeries/hospitalizations and Dates of Each
Please list all prescription medications (name and dosage)
Please list any known allergies (medications, foods, latex, etc.) and reactions.
Diagnosis of Your Condition
Please provide additional detail on your prior treatments (name, duration, outcome)
Please list any vitamins, supplements, over-the-counter drugs, or herbal or natural remedies (name and dosage)
Additional Comments Regarding Your Medical History
Prior Treatments for Your Condition
Chemotherapy (e.g. cytotoxic drugs for cancer or autoimmune conditions)
Immunotherapy (e.g. checkpoint inhibitors, monoclonal antibodies, or biologics)
Hormone therapy (e.g. tamoxifen, aromatase inhibitors, estrogen therapy)
Targeted therapy (e.g. BRCA inhibitors, HER2-targeted drugs)
Surgical intervention
Radiation therapy
Physiotherapy / Rehabilitation
Dietary or nutritional therapy
Psychological or psychiatric treatment
Other (please specify, max 200 characters)
Other (please specify, max 200 characters)
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Currently in another clinical trial or receiving investigational treatment?
Please Select
Yes
No
If yes, please specify the study or treatment.
Organ transplant history
Please Select
Yes
No
If yes, please specify which organ and when.
Menstrual Cycle Status
Please Select
Regular cycles
Irregular cycles
Perimenopause
Menopause (no period for 12+ months)
Post-menopause
No menstrual cycle (medical reason)
Not applicable
Prefer not to answer
Current Contraceptive Use
Please Select
None
Combined oral contraceptive pill
Progestogen-only pill
Hormonal IUD (e.g. Mirena)
Non-hormonal IUD (e.g. copper coil)
Contraceptive implant
Contraceptive injection
Barrier method (condom/diaphragm)
Natural family planning
Permanent contraception (sterilisation)
Not applicable
Prefer not to answer
Hormone Therapy Status
Please Select
Not currently on hormone therapy
HRT – oestrogen only
HRT – combined (oestrogen + progesterone)
Gender-affirming hormone therapy
Thyroid hormone therapy
Other hormone therapy
Prefer not to answer
If pregnant, please indicate trimester
First trimester (weeks 1–12)
Second trimester (weeks 13–26)
Third trimester (weeks 27–40)
Breastfeeding only (not currently pregnant)
Women's Health Profile
Menstrual Cycle Status
Please Select
Regular cycles (21–35 days)
Irregular cycles
Currently pregnant
Postmenopausal
Perimenopause
Amenorrhea (absent periods)
Not applicable
Prefer not to answer
Are you currently using any form of contraception or hormone therapy?
Please Select
No
Combined oral contraceptive pill
Progestogen-only pill (mini-pill)
Hormonal IUD (e.g. Mirena)
Non-hormonal IUD (e.g. copper coil)
Contraceptive implant
Contraceptive injection
Hormone Replacement Therapy (HRT)
Other (please specify)
Prefer not to answer
If other, please specify contraception or hormone therapy
If currently pregnant — trimester
Please Select
First trimester (weeks 1–12)
Second trimester (weeks 13–26)
Third trimester (weeks 27–40)
Not applicable
If currently breastfeeding — duration
Please Select
Less than 3 months
3–6 months
6–12 months
More than 12 months
Not applicable
Have you made any changes to your medications or hormone therapy in the last 3 months?
Yes
No
Not applicable
Please describe the medication changes (name, what changed, and when).
Trial Preferences
Recent Medication Changes
Current pregnancy or breastfeeding (if applicable)
Please Select
Pregnant
Breastfeeding
Neither
Reason for Entering the Trial
*
I actively and explicitly consent to participate in LUMIKEI MED's participant matching process
*
Signature
Areas of Interest or Study Preferences
Healthy volunteer studies (I am generally healthy and open to participating in trials for research purposes)
Condition-specific studies (I am interested in trials related to a diagnosed health condition I have)
Preventive or screening studies (e.g., lifestyle, vaccine, or early detection research)
Reproductive health studies (e.g., PCOS, endometriosis, fertility, menstrual health)
Mental health and wellness studies (e.g., depression, anxiety, stress, sleep)
Hormonal and endocrine studies (e.g., thyroid, menopause, diabetes, PCOS)
Pain management studies (e.g., migraine, pelvic pain, arthritis, fibromyalgia)
Rare disease studies
Clinical trials with investigational medication or devices
Natural or lifestyle intervention studies (e.g., diet, exercise, herbal supplements)
Other (please specify)
If other trial preference, please describe
Trial Types I Prefer Not to Explore
Radiation-based therapies
Reproductive health trials
Invasive surgical procedures
No preference
Other
If other please mention:
Informed Consent
*
I have read and understood the information provided in this form. I voluntarily consent to participate in the LUMIKEI MED participant matching process and confirm that all information I have provided is accurate to the best of my knowledge.
Support Needed or Preferred During Participation
Transportation assistance (e.g., to/from the clinical site)
Childcare support during appointments
Flexible appointment scheduling (evenings/weekends)
Home visits or remote participation options (telemedicine)
Language interpretation or translated materials
Assistance understanding medical information (health literacy support)
Emotional or mental health support during the study
A caregiver or family member to attend appointments with me
Assistance with reminders (calls, texts, or emails)
Access to a study coordinator or patient navigator
Information about compensation or reimbursement
I don’t need any additional support at this time
Other (please specify)
If other support is needed, please describe
Voluntary Participation
*
Accuracy of Information
*
Contact Permission
*
Medical Record Access
*
Welcome to the LUMIKEI MED Participant Enrolment Form. This form is designed to help us understand your health profile and trial preferences. All information provided is strictly confidential and will only be used for the purpose of matching you with suitable clinical research opportunities. Completing this form does not guarantee placement in a trial.
In accordance with EU Regulation 2016/679 (GDPR), your personal and health data will be collected, stored, and processed solely for clinical research matching purposes by LUMIKEI MED. You have the right to access, correct, or delete your data at any time by contacting us at info@lumikeimed.com. Your data will not be shared with third parties without your explicit consent.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
City
Country
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Please Select
Social Media
LinkedIn
referral from a friend or colleague
Healthcare Provider
Event or Conference
Google Search
Other
By signing below, you confirm that: (1) you are participating voluntarily and may withdraw at any time, (2) the information provided is accurate to the best of your knowledge, (3) you consent to LUMIKEI MED contacting you regarding relevant trials, and (4) you authorise access to relevant medical records if required for trial matching purposes.
This form represents an expression of interest in participating in clinical research. Submission does not constitute enrolment in any clinical trial. LUMIKEI MED will review your information and contact you if a suitable opportunity becomes available.
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