CoQ10 PK Study Pre-Screener Questionnaire
This survey will take no longer than 5 minutes of your time to complete and is intended to assess your eligibility for this KGK Science clinical trial. This clinical trial will investigate and compare the bioavailability and pharmacokinetics of three Coenzyme Q10 formulations. You do not have to answer all the questions if you do not feel comfortable doing so, but we do need the answers to qualify you for the study.
We would like 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. https://kgkscience.com/privacy/
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Please indicate your preferred contact method:
*
Please Select
Email
Text
Phone
Any
Please indicate the best time of day to reach you.
Please Select
9-12pm
12-3pm
3-5pm
5-8pm
Are you available to visit KGK Science for 13-hour days every other week, plus small 30-minute follow-up visits in the next 6 weeks? Example: Monday March 30th, Monday April 14th etc.
*
Please Select
Yes
No
Unsure
Please Enter Your Date of Birth
-
Month
-
Day
Year
Date
What was you assigned sex at birth?
*
Please Select
Male
Female
Are you presently pregnant, planning to become pregnant or presently breastfeeding?
Please Select
Yes
No
Unsure
Please enter your height
Inches
Please enter your weight
Pounds (lbs)
Have you experienced the following: (Please tick all that apply)
Difficulties with blood tests
Trouble finding veins
Uncomfortable with a cather being place in your arm for blood draw
None of the above
Please select the type of diet you follow:
Please Select
Regular
Vegan
Vegetarian
Keto
Paleo
Other
On average, how many standard drinks do you consume per week?
Please Select
Less than 2
3-4
5-6
7-8
10-14
15 or more
Do you use tobacco/nicotine products?
Please Select
I currently smoke
No, I no longer smoke
I have never smoked.
Do you use cannabis
No
Prescription Cannabis
Recreational Cannabis
How often do you use recreational cannabis?
Please Select
I don't
Daily- 5+ times per week
Weekly-2-3 times per week
Monthly-1-2 times per week
Occasionally- less than once per month
Please list any food allergies/sensitities you have.
Do you have a history of or currently have any of the following medical conditions? (Please tick all that apply)
Diabetes (Type 1 or Type 2)
Thyroid Related Disorders
Chronic Kidney or Liver Diseases
High Cholesterol
High Blood Pressure
GI (Gastrointestinal) Issues or Diseases (e.g. IBS, Crohn's, Ulcerative Colitis)
Cardiovascular Disease or History of Cardiac Events
Psychiatric Conditions
Metabolic Conditions
Chronic Inflammatory Conditions
Immune-Compromised/Autoimmune Conditions
Hep B, Hep C or HIV
Blood/Bleeding Disorders
Neurological Conditions
None of the above
Is your medical condition currently stable, that is, are you being followed by a physician and taking prescribed medication to control your condition?
Yes
No
Unsure
Do you take any of the following prescription medications? (Please select all that apply)
Blood Thinners
Blood Pressure Medications
Statins (Cholesterol-Lowering Medications)
How long have you been taking these medications
Please Select
Just started
Less than 3 months
3-6 months
>6 months
How did you hear about this study? Please select all that apply.
Meta (Facebook/Instagram)
Website
Google
Someone Referred Me
TikTok
Other
Please list the name/email of the person who referred you so we can thank them.
Why did you decide to participate in this study?
Interest in the topic being studied
Compensation for my participation
I have done clinical trials before
Other
Additional Comments or Concerns
We will contact you within 2-3 business days.
I consent (by submitting the form) to receiving communications from KGK Science Inc. and their third-party service providers via email, text and phone.
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