Rousselot 25RCCT03 Focus & Attention Study Pre-screen

Focus and Attention 25RCCT03 Pre-Screener Questionnaire

This survey will take no longer than 5 minutes to complete and is intended to assess your eligibility for this KGK Science clinical research study. This clinical research study evaluates the efficacy of a dietary supplement on healthy young adults with self-reported attention problems.
All Information is collected and will be kept in accordance with KGK Science's privacy policy (www.kgkscience/privacy).
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate your preferred contact method:
Please indicate the best time of day to reach you.
Please Enter Your Date of Birth

MonthDayYear
Date
What was you assigned sex at birth?
Are you presently pregnant, planning to become pregnant or presently breastfeeding?
Please enter your height
Inches
Please enter your weight
Pounds (lbs)
Do you find you have attention problems or difficulties keeping focus?
Have you been diagnosed with cognitive impairments?
Have you been diagnosed with ADD or ADHD (Attention Deficit Hyperactivity Disorder)?
Approximately how many caffeinated beverages would you 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/sensitivities 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
If you do not qualify, do we have your permission to retain your contact information for future studies? (If you do not consent, your information will be deleted/destroyed at the end of this recruitment process)
We will contact you within 2-3 business days.

I consent (by submitting the form) to receiving communications from KGK Science Inc. and their third-party service providers via email, text and phone.
Should be Empty:

Focus and Attention 25RCCT03 Pre-Screener Questionnaire

We will contact you within 2-3 business days.