24QSCFA02 Quick Silver Questionnaire

1
Do we have your consent to ask you some questions related to your lifestyle and medical history and to contact you regarding this study? (If you answer No, this survey will end). If you answer NO, this survey will end.
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
Will you be able to commit to answer all requested online questionnaires to study completion?
YESNO
8
Please Enter Your Date of Birth
Date
Year
Month
Day
9
What is your current height?
Height Number
Please Select
Please Select
CM
INCHES
Height Metric
10
What is your current weight?
Weight Number
Please Select
Please Select
KG
LBS
Weight Metric
11
What was your assigned sex at birth?
Male
Female
12
Are you presently pregnant, planning to become pregnant or breastfeeding?
Yes
No
I can no longer become pregnant
13
Being as you are female; it is important that during this study you do not become pregnant. What method of birth control are you currently using and will continue to use during the duration of the study.
Hormonal contraceptives (Oral, birth control patches, Vaginal Contraceptives (NuvaRing), Injectable contraceptives (Depo-Provera, Lunelle) or hormone Implants (Norplant System)
Double-Barrier method
Intrauterine Device
Non-heterosexual lifestyle or you agree to use contraception if planning on changing to heterosexual lifestyle
Vasectomy of partner (must have occurred at least 6 months ago)
Abstinence
Currently not using any form of birth control
14
Please indicate the reason you can no longer become pregnant
Hysterectomy
Bilateral Oophorectomy
Bilateral Tubal Ligation
Complete Endometrial Ablation
Menopause (for at least 1 year)
15
Have you been told by your doctor that you elevated sugar (high blood sugar)?
YESNO
16
Are you aware of what a GLP-1 or semaglutide is?
YESNO
17
Has your doctor previously recommended that you might want to try using a GLP-1 product?
YESNO
18
Was the GLP-1 recommended for better sugar control or for weight loss?
Sugar Control
Weight Loss
Both
19
Are you currently on any prescribed treatments to control your blood sugar?
YESNO
20
What is the prescribed treatment/medication that you are taking?
21
Have you gained or lost more than 5kg of your body weight in the past in the past 3 months?
YESNO
22
Do you have or have a family history of medullary thyroid cancer (MTC)?
YESNO
23
Do you or does anyone in your family have Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)?
YESNO
24
Have you been diagnosed with Diabetes?
YESNO
25
What type of diabetes?
Type 1 (juvenile onset)
Type 2-non-insulin dependant
Type 2- insulin dependant
26
Have you been diagnosed with Diabetic Ketoacidosis?
YESNO
27
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
28
On average, how many standard alcoholic drinks do you consume per week?
None
1-2 drinkts
3-4 drinks
5-7 drinks
7-10 drinks
10-14 drinks
14+ drinks
29
Do you use tobacco or nicotine products (e.g., cigarettes, vapes, e-cigarettes)?
I currently smoke/vape
No, I no longer smoke/vape.
I have never smoked/vaped.
30
Do you use cannabis products?
YESNO
31
Reason for Using Cannabis
Prescribed by Health Provider
Recreational Use
32
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
33
How do you consume cannabis?
Drops
Edibles
Smoking/Vaping
Cream
Other
34
Have you had a major surgery in the past 3 months or plan to have surgery in the next 3 months?
YESNO
35
What type of surgery was/is it?
36
Have you been diagnosed with any of the following medical conditions?
Type 1 or Type 2 Diabetes
Thyroid-Related Disorder
Chronic Kidney or Liver Disease
High Cholesterol
Hypertension (High Blood Pressure)
Cardiovascular Disease
Current or History of Gastrointestinal Issues
Gastrointestinal Diseases ( e.g., IBS, Crohn's, Ulcerative Colitis, IBD)
Metabolic Disease (PCOS, Metabolic Syndrome e.g.)
Autoimimmune Disease or Immune Compromised
HIV, HepB or Hep C Positive
Blood/Bleeding Disorders
Musculoskeletal Disorders
Urogential Disease/Disorders (STD,UTIs CIN)
History of Psychiatric Condition
Other
37
If other, please indicate you condition.
38
Did you select kidney issues because you have/had kidney stones?
YESNO
39
Have you been symptoms free for the past 6 months?
YESNO
40
Have you had a significant cardiovascular events in the past 6 months?
YESNO
41
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
42
Are you taking medications to control your condition?
YESNO
43
How long have you been taking your medications
1-2 months
3-5 months
Over 6 months
Over 1 year
44
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
45
Please indicate which, if any, of the following prescription medications you take:
Glucose (blood sugar) lowering meds
GLP-1 Agonists (e.g., Ozempic, Saxenda, Victoza)
Insulin
Weight loss medications or appetite suppressants
Medications that you have been told could effect your weight
46
Are you currently taking other prescribed medications
YESNO
47
Please list your medications.
48
Do you use any of the following over-the-counter medications or supplements?
Over-the-counter weight loss medications
Supplements to improve your glucose control
Marketed weight-loss supplements (some examples are Hydroxycut, thermogenic supplements)
49
Have you been taking these over-the-counter medications/supplements for at least 3 months?
YESNO
50
Do you use any over-the-counter medication or natural health products regularly?
YESNO
51
Please list below:
52
Have you donated blood in the last 30 days or plan to in the next 30 days post?
YESNO
53
Have you participated in a clinical trial within the last 30 days?
YESNO
54
Please enter the date the clinical trial participation ended?DD/MM/YYYY
55
How did you hear about this study?Please tick all that apply
Facebook
Instagram
Email
Website
Radio
Google
Flyers
Reddit
YouTube
TikTok
Someone Referred Me
Other
56
Please describe where you heard about that study.
57
Please provide contact information for the person who referred you so we can thank them. Name & Email
58
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
59
What was the other reason you decided to apply?
60
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
Should be Empty: