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
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Date of Birth

MonthDayYear
Date
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