High Cholesterol Study Pre-Screen
Adults with persistently high cholesterol despite medication.
Full Name
*
First Name
Last Name
(City, State, Zip Code)
*
Street Address
Street Address Line 2
City
State
Zip Code
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Do you have a history of heart attack with stent placement and/or history of CABG (coronary artery bypass)? *if yes, has this happened in the last 6 months?
*
Yes (in the last 6 months)
Yes (more than 6 months ago)
No
Do you take any medications for cholesterol? (If, yes please list medications in the next box)
*
Yes
No
Please list any current cholesterol medications (name and dose):
Have you had cholesterol lab work done in the past 6 months? If yes, do you have a copy of the report?
*
Yes, and I HAVE a copy of the report
Yes, but I DO NOT have a copy of the report
No
Check all that apply to your medical history
*
Diagnosed with cardiovascular disease
Diagnosed with severe hyper triglycerides
Diagnosed with hypercholesterolemia
Diagnosed with mixed hyperlipidema
Diagnosed with liver disease
Uncontrolled diabetes
Uncontrolled high blood pressure
Significant blood clotting disorder
Stroke
History of alcohol or substance abuse
HIV
Hepatitis B
Hepatitis C
Cancer within the last 5 years
Uncontrolled heart rhythms (tachycardia or bradycardia)
Currently taking steroids
Currently taking fish oil supplements
Currently taking red yeast rice supplements
None of the above
Are you willing and able to undergo a MRI scan needed as part of the study?
*
Yes
No
Female-Only Criteria
Check all that apply
Currently of child bearing potential
Postmenopausal
Surgically sterile (Tubal ligation or Salpingectomy)
Comments or questions:
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