Fatty Liver Study

FATTY LIVER PRE-SCREEN

Please fill out the this pre-screen form to be considered for this clinical trial. Please allow 24-48 hours for one of our staff members to contact you regarding your submission.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
How did you hear about us?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Height (ft & in)
Weight (lbs)
BMI
Are you currently enrolled in any other study?
Do you have Type 1 or Type 2 diabetes?
Have you ever been diagnosed or at risk for liver disease?
Are you currently taking any GLP-1 medications?
Do you have a current or past history of alcohol abuse?
In the last 3 months, have you had any of the following: stroke, heart attack or any hospitalization due to heart failure?
Have you ever been diagnosed with cancer?
Have you ever been diagnosed with an auto-immune disease?
Please list all medications that you are currently taking:
Should be Empty:

FATTY LIVER PRE-SCREEN