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Amino Acid and Aging Study
Please fill out and submit this form to join our study
47
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Language
English (US)
1
Consent
This survey will take no longer than 5 minutes of your time to complete and is intended to assess your eligibility for the KGK Science clinical trial. This clinical trial will investigate the efficacy and safety of a natural health product Amino Acid Supplement on increasing serum IGF-1 (insulin-like growth factor 1) concentrations within adults aged 35-75.
Do we have your consent to ask you some questions relating to your lifestyle and medical history and to contact you regarding this study? (IF you answer NO, this survey will end)
YES
NO
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2
Name
First Name
Last Name
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3
Email
example@example.com
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4
Phone Number
Please enter a valid phone number.
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5
Please Indicate your preferred contact method:
Email
Text
Phone
Any
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6
Are you available to visit KGK Science in London, ON, five (5) times over a period of approximately three (3) months?
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NO
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7
Please Select Your Sex:
Male
Female
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8
Are you presently pregnant, planning to become pregnant, or currently breastfeeding?
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NO
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9
Please Enter Your Date of Birth
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Date
Year
Month
Day
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10
Please Enter Your Height
Please enter a number
CM
Inches
Feet
CM
Inches
Feet
Measurement
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11
Please Enter Your Weight
Please enter a number
Lbs
Kg
Lbs
Kg
Measurement
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12
Have you had a history of alcohol or illicit drug abuse, known drug dependence, or are you seeking treatment for alcohol or substance abuse-related disorders within the past 24 months (about 2 years)?
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NO
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13
On Average, how many standard alcoholic drinks do you consume per week?
None
Two or Less
3 to 5
6 to 9
10-14
15 or more
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14
Does your employment involve shift work?
YES
NO
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15
Does one of your shifts require you to work a night shift?
YES
NO
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16
Are you planning to travel across one or more time zones in the next 3 months?
YES
NO
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17
Are you allergic to any of the following:
L-Lysine hydrochloride
L-Arginine hydrocholoride
L-Pyroglatimic Acid
Fermented extact of n-acetyl l-cysteine
L-Glutamine
Schizonepeta (aerial parts) powder
Gelatin
Magnesium Stearate
Stearic Acid
Rice Flour
Silicon Dioxide
Titanium
Dioxide
Microcrystalline cellulose
Other
None
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18
Please List Allergies:
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19
Are you willing to take supplements that contain gelatin for the duration of the study?
YES
NO
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20
Have you had any major surgery in the past 3 months?
YES
NO
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21
If Yes, what type of surgery?
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22
Are you planning on having surgery in the next 3-4 months?
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23
If Yes, what type of surgery?
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24
Do you have a condition known to directly involve and/or affect ICG-1 including dwarfism, malnutrition, pituitary disorders, or Laron Sydrome?
YES
NO
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25
Do you have any of the following medical conditions:
Diabetes Type 1
Diabetes Type 2
High Blood Pressure
Dementia/Alzheimer's
Thyroid-Related Disorder
Chronic Kidney Disease
Pancreatic Disease
Liver Disease
High Cholesterol
High Triglycerides
High Blood Pressure
History of Gastrointestinal (Including Bariatric bypass surgery), Hepatic or Renal Disease
History of Cardiovascular Disease
Auto-Immune Disease or are Immune-Compromised
Other
None
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26
If Other, please indicate your medical condition:
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27
Is your medical condition currently in stable condition, that is, are you being followed by a physician and taking prescribed medication to control your condition?
YES
NO
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28
Please use this space to provide more information about medical conditions.
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29
Have you been diagnosed with Cancer within the past 5 years, or are you currently receiving chemotherapy or radiation treatment? This does not include basal cell carcinoma that has been fully excised without chemotherapy or radiation?
YES
NO
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30
Please indicate which, if any, of the following prescriptions you have taken in the last 3 months.
Aminocyclitol and/or Penicillin Antibiotics (Such as neomycin, streptomycin, kanamycin, gentamicin, tobramycin, ampicillin, methicillin, isoxazolyl, penicillin G)
Nitroglycerin
Synthetic Form of HGH or IGF-1
None of the abovve
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31
When did you or are you due to stop this medication?
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32
Do you use any other prescription medications?
YES
NO
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33
Please list your prescription medications, doses, frequency and the reason for use.
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34
Are you or have you been taking any antibiotics in the last 3 months?
YES
NO
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35
Please list which antibiotic and when you stopped or will stop taking them.
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36
Do you use any over-the-counter medication or natural health products regularly?
YES
NO
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37
Please list your over-the counter medications and/or supplements, dose, and frequency.
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38
Would you be willing to stop taking these over-the-counter medications and supplements listed previously during the study or prior to study visits as required?
YES
NO
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39
Will you be willing to maintain your current lifestyle habits throughout the study, including medications, supplements, and sleep?
YES
NO
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40
Have you participated in a clinical trial within the last 30 days?
YES
NO
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41
Please enter the date the clinic trial participation ended.
-
Date
Year
Month
Day
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42
How did you hear about this study
Facebook
Instagram
Email
Website
Radio
Google
Flyers
Someone Refered me
Other
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43
Other Advertisement: Please Fill In
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44
Who Referred You: Please fill out First Name, Last Name and Email so we can thank them.
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45
Why did you decide to apply for participation in this study?
Interested in topic being studied
Compensation being offered for particpation
I have participated in clinical trials before
Type option 4
Other
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46
Other Reason: Please fill in
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47
Opt-In Communication:
I consent to receive communications form KGK Science Inc. and their third-party service providers via electronic mail, electronic message, telecommunications, and automatic dialing-announcing device, including the use of prerecorded or synthesized voice messages.
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