Rousselot 25RCCT02 Memory & Cognition Study Pre-screen

Memory & Cognition 25RCCT02 Pre-Screener Questionnaire

This survey will take no longer than 5 minutes to complete and is intended to assess your eligibility for the KGK Sci
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 NameLast Name
Email Address
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Phone Number
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Please Enter Your Date of Birth

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Date
What was you assigned sex at birth?
Are you presently pregnant, planning to become pregnant or presently breastfeeding?
Please enter your height
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Please enter your weight
Pounds (lbs)
Do you find yourself forgetting the names of family or friends (or calling them by different names)?
Do you find yourself forgetting the name of common things or use the wrong names?
Do you find yourself forgetting where you have put something or losing things around the house?
Approximate how many caffeinated beverages you would drink on a regular day? (consider any beverage that contains caffeine, tea, coffee, energy drinks)
During the study will you be able to avoid high sources of caffeine (e.g. Supplements, tea, coffee, energy drinks) & alcohol for 24 hours prior to in-clinic visits?
Have you been diagnosed with colour blindness/weakness?
On average, how many standard drinks do you consume per week?
Do you use tobacco/nicotine products?
Do you use cannabis
How often do you use recreational cannabis?
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)
Is your medical condition currently stable, that is, are you being followed by a physician and taking prescribed medication to control your condition?
Do you take any of the following prescription medications? (Please select all that apply)
Do you use any of the following supplements? (Please select all that apply)
How long have you been taking these medications
How did you hear about this study? Please select all that apply.
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?
Please select the Day(s) of the week you would be available for a screening appointment. Please select all that apply.
Please select the preferred time of day. Please select all that apply.
Additional Comments or Concerns
We will contact you within 2-3 business days.

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Memory & Cognition 25RCCT02 Pre-Screener Questionnaire

We will contact you within 2-3 business days.