Amino Acid and Aging Study 35-75

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)

YESNO

Name

First Name

Last Name

example@example.com

Phone Number

Please enter a valid phone number.

Please Indicate your preferred contact method:

Text

Phone

Any

Are you available to visit KGK Science in London, ON, five (5) times over a period of approximately three (3) months?

YESNO

Please Select Your Sex:

Male

Female

Are you presently pregnant, planning to become pregnant, or currently breastfeeding?

YESNO

Please Enter Your Date of Birth

Date

Please Enter Your Height

Please enter a number

Measurement

Please Enter Your Weight

Please enter a number

Measurement

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)?

YESNO

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

Does your employment involve shift work?

YESNO

Does one of your shifts require you to work a night shift?

YESNO

Are you planning to travel across one or more time zones in the next 3 months?

YESNO

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

Please List Allergies:

Are you willing to take supplements that contain gelatin for the duration of the study?

YESNO

Have you had any major surgery in the past 3 months?

YESNO

If Yes, what type of surgery?

Are you planning on having surgery in the next 3-4 months?

YESNO

If Yes, what type of surgery?

Do you have a condition known to directly involve and/or affect ICG-1 including dwarfism, malnutrition, pituitary disorders, or Laron Sydrome?

YESNO

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

If Other, please indicate your medical condition:

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?

YESNO

Please use this space to provide more information about medical conditions.

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?

YESNO

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

When did you or are you due to stop this medication?

Do you use any other prescription medications?

YESNO

Please list your prescription medications, doses, frequency and the reason for use.

Are you or have you been taking any antibiotics in the last 3 months?

YESNO

Please list which antibiotic and when you stopped or will stop taking them.

Do you use any over-the-counter medication or natural health products regularly?

YESNO

Please list your over-the counter medications and/or supplements, dose, and frequency.

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?

YESNO

Will you be willing to maintain your current lifestyle habits throughout the study, including medications, supplements, and sleep?

YESNO

Have you participated in a clinical trial within the last 30 days?

YESNO

Please enter the date the clinic trial participation ended.

Date

How did you hear about this study

Facebook

Instagram

Website

Radio

Google

Flyers

Someone Refered me

Other

Other Advertisement: Please Fill In

Who Referred You: Please fill out First Name, Last Name and Email so we can thank them.

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

Other Reason: Please fill in

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.