24EMCFA01-Enzymedica Memory Study

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If you do no qualify, do we have your permission to retain your contact information for future studies?If you do not qualify and do not consent, your information will be deleted/destroyed at the end of this recruitment process.
YESNO
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Your Privacy Is Important to Us

We want 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
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Name
First Name
Last Name
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Email
example@example.com
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Phone Number
Please enter a valid phone number.
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Postal Code
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Please Enter Your Date of Birth
Date
Year
Month
Day
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What is your current height?
Height Number
Please Select
Please Select
CM
INCHES
Height Metric
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What is your current weight?
Weight Number
Please Select
Please Select
KG
LBS
Weight Metric
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What was your assigned sex at birth?
Male
Female
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Are you presently pregnant, planning to become pregnant or presently breastfeeding?
Yes
No
I can no longer get pregnant.
12
Which type of birth control are you using?
I am no longer able to get pregnant (e.g., menopause (over 12 months), hysterectomy, bilateral oophorectomy, bilaterial tubal ligation, complete endometrial ablation)
Hormonal contraceptives
Double-Barrier method
Intrauterine Device
Non-heterosexual lifestyle
Vasectomy of partner (must have occurred at least 6 months ago)
Abstinence
13
To help us better understand the diversity of our participants and ensure we are providing inclusive and equitable services, could you please let us know your racial or ethnic background? This information will be kept confidential and used only for demographic analysis. Choose all that apply.
African American or Black
Central American
South American
South Asian
East Asian
Middle Eastern
South East Asian
Southeast Asian
Indigenous or First Nations
Eastern European White
Western European White
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Have you had a history of alcohol or illicit drug abuse, known drug dependence, or are seeking or have sought treatment for alcohol or substance abuse related disorders within the past 12 months?
YESNO
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Do you regularly drink alcohol?
YESNO
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On average, how many standard alcoholic drinks do you consume per week?
None
Two or Less
3 to 5
6 to 9
10 to 14
14+
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Do you use tobacco or nicotine products (e.g., cigarettes, vapes, e-cigarettes)?
I currently smoke.
No, I no longer smoke.
I have never smoked.
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Do you use cannabis products?
YESNO
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Reason for Using Cannabis
Prescribed by Health Care Provider
Recreational Use
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How often do you use recreational 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
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How do you consume cannabis?
Drops
Edibles
Smoking/Vaping
Cream
Other
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Will you be able to refrain from consuming cannabis before and during the study period?
YESNO
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Have you been diagnosed with any of the following medical conditions?
Type 1 or Type 2 Diabetes
Thyroid-Related Disorder
Chronic Kidney or Liver Disease or Pancreatic Disease
High Cholesterol
Hypertension (High Blood Pressure)
Current or History of Gastrointestinal Issues (e.g., IBS, Crohn's, Ulcerative Colitis, IBD)
History of Cardiovascular Disease or Cardiac Event
History of Psychological Conditions (ex. Depression, Anxiety, Bipolar, Schizophrenia, Psychosis, etc.)
Metabolic Disease (PCOS, Metabolic Syndrome e.g.)
Chronic Inflammatory Diseases (for example Graves/Hashimoto's , Lupus, COPD, Psoriasis, Rheumatoid Arthritis)
Autoimimmune Disease or Immune Compromised
HIV, HepB or Hep C Positive
Other
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If other, please indicate you condition.
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Did you select kidney issues because you have/had kidney stones?
YESNO
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Have you been symptoms free for the past 6 months?
YESNO
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Have you had any significant cardiovascular events in the past 6 months?
YESNO
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Is your medical condition currently in stable condition (have been treated for at least 3 months with no changes in medications), that is, you are being followed by a physician and taking prescribed medication to control their condition?
YESNO
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Have you had/been diagnosed with cancer in the past 5 years?
YESNO
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Was it skin cancer (basal cell carcinoma)?
YESNO
31
Are you currently receiving chemotherapy or radiation treatment?
YESNO
32
Have you had a major surgery in the past 3 months or plan to have surgery in the next 3 months?(including gastric bypass or other weight loss surgeries)
YESNO
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Have you been experiencing memory issues?
YESNO
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Have you been diagnosed with dementia?
YESNO
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Have you been diagnosed with other cognitive impairments?
YESNO
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Do you find yourself forgetting the names of friends or relatives? (do you call them by the wrong names)
Several Times a Day
About Once a Day
Once or Twice a Week
Less than Once a Week
Never
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Do you find yourself forgetting the name of common things or use the wrong names?
Several Times a Day
About Once a Day
Once or Twice a Week
Less than Once a Week
Never
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Do you find yourself forgetting where you have put something or lose things around the house?
Several Times a Day
About Once a Day
Once or Twice a Week
Less than Once a Week
Never
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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?
YESNO
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Have you been diagnosed with colour blindness/weakness?
YESNO
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Please indicate which, if any, of the following prescription medications you take:
Benzodiazepines
Sedatives
Opiates
Mood Stabilizers
Antidepressants
Antipsychotics
Anti-Allergy Medications
Lipase Inhibitors (e.g. Orlistat)
Gabapentin or Pregabalin
Other
None of the above
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Please list Other Medications
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How long have been on this prescribed medication?
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Do you use any of the following over-the-counter medications or supplements?
Supplements containing St. John's Wort, Panax, Ginseng, Ginkgo Biloba
Digestive Enzymes
Prebiotic, probiotic, and fiber supplements (e.g. Metamucil, Benefiber)
Products containing tributyrin and/or butyrate
Anti-Allergy Medication
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How long have you been taking them?
Less than 30 days
1-2 Months
3-4 Months
>6 Months
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Have you been part of a research study before?
YESNO
47
When was the last time you completed (are no longer taking products or being observed for research results) a research study?
1 Month Ago
3-6 Months Ago
More Than 6 Months Ago
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Do you have any upcoming holiday plans or trips that may alter your regular dietary patterns?
YESNO
49
How did you hear about this study?Please tick all that apply
Facebook
Instagram
Email
Website
Radio
Google
Flyers
Reddit
YouTube
TikTok
Someone Referred Me
Other
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Please describe where you heard about that study.
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Please provide contact information for the person who referred you so we can thank them. Name & Email
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Why did you decide to apply for participation in this study?
Interest in the topic being studied
Compensation being offered for participation
Have participated in clinical trial before.
Other
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What was the other reason you decided to apply?
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I consent to receiving communications from KGK Science Inc. and their third-party service providers (via electronic mail, electronic message, telecommunication, and automatic dialing-announcing device including the use of pre-recorded or synthesized voice messages). Your information will not be shared with and/or sold to external companies and is only used for communications with KGK Science.
YESNO
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