26LBKGR01- Pre-Diabetic

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Do we have your consent to ask you some questions related to your lifestyle and medical history and to contact you regarding this study? (If you answer No, this survey will end). If you answer NO, this survey will end.
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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Are you available to visit KGK Science in London, ON, 5 times (5x) over approximately 2 months ?
YESNO
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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 breastfeeding?
Yes
No
I can no longer become pregnant
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Being as you are female; it is important that during this study you do not become pregnant. What method of birth control are you currently using and will continue to use during the duration of the study.
Hormonal contraceptives (Oral, birth control patches, Vaginal Contraceptives (NuvaRing), Injectable contraceptives (Depo-Provera, Lunelle) or hormone Implants (Norplant System)
Double-Barrier method
Intrauterine Device
Non-heterosexual lifestyle or you agree to use contraception if planning on changing to heterosexual lifestyle
Vasectomy of partner (must have occurred at least 6 months ago)
Abstinence
Currently not using any form of birth control
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Please indicate the reason you can no longer become pregnant
Hysterectomy
Bilateral Oophorectomy
Bilateral Tubal Ligation
Complete Endometrial Ablation
Menopause (for at least 1 year)
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Have you been told by your doctor that you elevated sugar (high blood sugar)?
YESNO
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Have you been diagnosed as pre-diabetic in the past?
YESNO
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Have you had any significant (>5% of your body weight) weight changes in the past 3 months?
YESNO
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When you get your blood taken, do they have issues taking the blood?
YESNO
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Do you have problematic veins to find?
YESNO
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How much vigorous (high-intensity physical activity that significantly elevates heart rate and breathing, making it difficult to speak more than a few words without pausing for breath)
< 30 minutes
30-60 minutes
61-90 minutes
91-120 minutes
>120 minutes
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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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On average, how many standard alcoholic drinks do you consume per week?
None
1-2 drinkts
3-4 drinks
5-7 drinks
7-10 drinks
10-14 drinks
14+ drinks
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Do you use tobacco or nicotine products (e.g., cigarettes, vapes, e-cigarettes)?
I currently smoke/vape
No, I no longer smoke/vape.
I have never smoked/vaped.
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Do you use cannabis products?
YESNO
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Reason for Using Cannabis
Prescribed by Health 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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Do you have any allergies or food sensitivities?
YESNO
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Please List Your Allergies or Food Sensitivities
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Have you had a major surgery in the past 3 months or plan to have surgery in the next 3 months?
YESNO
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What type of surgery was/is it?
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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
High Cholesterol
Hypertension (High Blood Pressure)
Cardiovascular Disease
Current or History of Gastrointestinal Issues
Gastrointestinal Diseases ( e.g., IBS, Crohn's, Ulcerative Colitis, IBD)
Metabolic Disease (PCOS, Metabolic Syndrome e.g.)
Autoimimmune Disease or Immune Compromised
HIV, HepB or Hep C Positive
Blood/Bleeding Disorders
Musculoskeletal Disorders
Urogential Disease/Disorders (STD,UTIs CIN)
History of Psychiatric Condition
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 a 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 or are you currently receiving chemotherapy or radiation?This does not include skin cancer (basal cell carcinoma) that has been fully excised without chemotherapy or radiation.
YESNO
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Please indicate which, if any, of the following prescription medications you take:
Steroids
Diurectics
Metformin or Insulin Sensitizers
GLP-1 Agonists (e.g., Ozempic, Saxena, Victoza, Wegovy)
Digoxin
Bile sequestrants (e.g., Cholestyramine and Colestipol)
Other Medications known to affect weight.
None of the above
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Are you currently taking other prescribed medications
YESNO
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Please list your medications.
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Do you use any of the following over-the-counter medications or supplements?
Supplements used to improve glycemic control (such as Alpha lipoic acid, chromium, berberine, aloe vera, ginger, cinnamon)
Glucosamine
Biotin
Decongestants (i.e. ephedrine, pseudoephedrine)
Supplements containing vinegar
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Have you been taking these over-the-counter medications/supplements for at least 3 months?
YESNO
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Do you use any over-the-counter medication or natural health products regularly?
YESNO
45
Please list below:
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Have you donated blood in the last 30 days or plan to in the next 30 days post?
YESNO
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Have you participated in a clinical trial within the last 30 days?
YESNO
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Please enter the date the clinical trial participation ended?DD/MM/YYYY
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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
Should be Empty: