Aker Biomarine- Memory Study

1

If you do no qualify, do we have your permission to retain your contact information for future studies?If you do not qualify and do not consent, your information will be deleted/destroyed at the end of this recruitment process.

YESNO

2

Your Privacy Is Important to Us

We want to ensure the data we collect can be verified by researchers and send updates on the study should you qualify to participate. All information recorded will be maintained with the strictest confidentiality except as required by law. For more information, please review our Privacy Policy

3

Name

First Name

Last Name

4

Email

example@example.com

5

Phone Number

Please enter a valid phone number.

6

Postal Code

7

Please Enter Your Date of Birth

Date

8

What is your current height?

Height Number

Height Metric

9

What is your current weight?

Weight Number

Weight Metric

10

What was your assigned sex at birth?

Male

Female

11

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

Yes

No

I can no longer get pregnant.

12

Which type of birth control are you using?

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

Hormonal contraceptives

Double-Barrier method

Intrauterine Device

Non-heterosexual lifestyle

Vasectomy of partner (must have occurred at least 6 months ago)

Abstinence

14

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

15

Do you regularly drink alcohol?

YESNO

17

Do you use tobacco or nicotine products (e.g., cigarettes, vapes, e-cigarettes)?

I currently smoke.

No, I no longer smoke.

I have never smoked.

18

Do you use cannabis products?

YESNO

19

Reason for Using Cannabis

Prescribed by Health Care Provider

Recreational Use

20

How often do you use recreational cannabis?

Daily or 5-7+ times per week

Regularly or 3-4 times per week

Weekly or 1-2 times per week

Monthly or 1-3 times per month

Occasionally / less than once per month

22

Will you be able to refrain from consuming cannabis before and during the study period?

YESNO

24

If other, please indicate you condition.

25

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

YESNO

26

Have you been symptoms free for the past 6 months?

YESNO

27

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

YESNO

28

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

29

Have you had/been diagnosed with cancer in the past 5 years?

YESNO

30

Was it skin cancer (basal cell carcinoma)?

YESNO

31

Are you currently receiving chemotherapy or radiation treatment?

YESNO

32

Have you had a major surgery in the past 3 months or plan to have surgery in the next 3 months?(including gastric bypass or other weight loss surgeries)

YESNO

33

Have you been experiencing memory issues?

YESNO

34

Have you been diagnosed with dementia?

YESNO

35

Have you been diagnosed with other cognitive impairments?

YESNO

36

Do you find yourself forgetting the names of friends or relatives? (do you call them by the wrong names)

Several Times a Day

About Once a Day

Once or Twice a Week

Less than Once a Week

Never

37

Do you find yourself forgetting the name of common things or use the wrong names?

Several Times a Day

About Once a Day

Once or Twice a Week

Less than Once a Week

Never

38

Do you find yourself forgetting where you have put something or lose things around the house?

Several Times a Day

About Once a Day

Once or Twice a Week

Less than Once a Week

Never

39

Will you be able to avoid high sources of caffeine (e.g., Supplements, tea, coffee, energy drinks) & alcohol for 24 hours prior to in-clinic visits?

YESNO

40

During the study will you be able to avoid moderate-vigorous exercise 12 hours before each clinic visit?

YESNO

41

Have you been diagnosed with colour blindness/weakness?

YESNO

42

Do you have any travel plans over the next 4 months?

YESNO

43

Do you regularly eat fish?

YESNO

44

If yes, what type of fish do you consume.

46

Please list Other Medications

47

How long have been on this prescribed medication?

48

Do you use any of the following over-the-counter medications or supplements?

Omega 3 supplements

Supplements for Cognition or Memory

Anti-Allergy Medication

Non-Steroid Anti-Inflammatory Drugs (NSAIDS) (e.g. Asprin, Ibuprofen, Naproxen)

49

How long have you been taking them?

Less than 30 days

1-2 Months

3-4 Months

>6 Months

50

Have you been part of a research study before?

YESNO

51

When was the last time you completed (are no longer taking products or being observed for research results) a research study?

1 Month Ago

3-6 Months Ago

More Than 6 Months Ago

52

Do you have any upcoming holiday plans or trips that may alter your regular dietary patterns?

YESNO

54

Please describe where you heard about that study.

55

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

56

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

57

What was the other reason you decided to apply?

58

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