Fatty Liver Study

FATTY LIVER PRE-SCREEN

Please submit the pre-screen form to be considered for participation in this trial.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
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Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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Date of Birth *

MonthDayYear
Date
Height (ft & in)
Weight (lbs)
BMI
YesNo
Type 1Type 2No
Diagnosed with liver diseaseAt risk of liver diseaseNo
YesNo
YesNo
StrokeHeart AttackHospitalization due to heart failureNo
YesNo
YesNo
Please list all medications that you are currently taking:
Should be Empty:

FATTY LIVER PRE-SCREEN