Clone of 25RRCRR01-NAD+

1
Personal InformationPlease fill out all sections.
First Name
Last Name
Please enter your email
Please enter your phone
Post Code
Please Select
Please Select
Male
Female
What was your sex at birth?
2
Are you currently or planning to become pregnant or will be breastfeeding during this study period?
YESNO
3
Please enter your date of birth.
Date of Birth (YYYY-MM-DD)
Year
Month
Day
4
Please enter your current height and weight.
Height
Please Select
Please Select
Centimetres (CM)
Inches
Please select your height unit.
Weight
Please Select
Please Select
Kilograms (kg)
Pounds (lbs)
Please select your weight unit.
5
Do you use any of the following?Please select all that apply.
Nicotine
Tobacco
Cannabis
6
How Often do you use cannabis?
Daily or 5-7+ times per week
Regularly or 3-4 times per week
Weekly or 1-2 times per week
Monthly or 1-3 times per month
Occasionally / less than once per month
7
When You Use Cannabis Does it contain THC?
YESNO
8
What is the general dose of THC/CBDyou are used to consuming?
0-2mg
2-5mg
5-10mg
10-15mg
>15mg
9
Have you ever had an allergic reaction to THC before?
YESNO
10
Would you be willing to refrain from using cannabis for the duration of the study (with the exception of the study visits)?
YESNO
11
Have you been diagnosed with any of the following medical conditions?Please select all that apply.
Type 1 or Type 2 Diabetes
Thyroid-Related Disorder
Chronic Kidney or Liver Disease
High Cholesterol
High Blood Pressure
Current History of Gastrointestinal Issues ( e.g., IBS, Crohn's, Ulcerative Colitis, IBD)
History of Cardiovascular Disease or Cardiac Event
History of Psychiatric Condition (e.g., Depression, Anxiety, Bipolar, Schizophrenia, Psychosis etc.)
Metabolic Disease (PCOS, Metabolic Syndrome e.g.)
Chronic Inflammatory Disease (e.g., Graves, Hashimoto's, Lupus, COPD, Psoriasis, Rheumatoid Arthritis)
Immune-Compromised/Autoimmune Diseases
HIV, HepB or Hep C Positive
Diagnosed with Cancer in the last 5 years
Other
None
12
If other, please indicate your medical condition
13
Are you available to visit KGK Science in London, ON for 2x 14hour visits (+ a screening visit, 24h4 and 48hr short visits) over a period of approximately 3 weeks?
YESNO
14
Please indicate which, if any, of the following prescription medications you take:Please select all that apply.
Antidepressants
Proton Pump Inhibitors
Antibiotics
Protease Inhibitors
Cannabinoid-containing products
Seizure medication
Sedatives, hypnotics, opioids, benzodiazepines
GABA inhibitors
Warfarin
Antipsychotics
Beta Blockers
15
Please list any other medications you take:
16
Do you use any of the following over-the-counter medications or supplements?Please select all that apply.
St. John's Wort
Sedatives
Sleep-Aids
Pseudoephedrine
Food or beverages containing xanthine derivatives or xanthine related compounds (coffee, black/green tea, chocolate) or energy drinks . Decaffeinated drinks are accepted.
Protein supplements used in sports
Grapefruit, Seville orange, starfruit, pomegranate, pineapple, or pomelo
Any food containing poppy seeds
Herbal remedies, homeopathic and traditional medicines, probiotics, food supplements
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How long have you been taking them?
Less than 30 days
1-2 months
3-6 months
>6 months
18
How did you hear about this study?Please select all that apply
Facebook
Instagram
Email
Website
Radio
Google
Flyers
Reddit
YouTube
TikTok
Someone Referred Me
Other
19
If you do not qualify, do we have your permission to retain your contact information for future studies and contact your regarding this study? (If you do not qualify and do not consent, your information will be deleted/destroyed at the end of the recruitment process)
YESNO
20
By submitting this form you are consenting to KGK Science retaining your contact information for this studies and potential future studies. Your information will not be shared with and/or sold to external companies and is only used for communication with KGK Science.
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