Sweetener Study

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Full Name* This field is required.
First Name
Last Name
2
Have you been diagnosed with Type II Diabetes* This field is required.
Yes
No
3
Are you aged between 18-70?* This field is required.This is inclusive of 18 & 70
Yes
No
4
Hidden - Are you aged between 18-70?
Yes
No
5
Please specify your approx. weight & height in the boxes below* This field is required.Note: You can use the arrow symbol below to toggle between imperial & metric
6
Hidden - BMI Calculation
7
Hidden - BMI Form Value
8
Hidden - BMI Pass/Fail
9
Are you aged between 18-75?* This field is required.This is inclusive of 18 & 75
Yes
No
10
Hidden - Are you aged between 18-75?
Yes
No
11
Are you pregnant, breastfeeding or planning a pregnancy?* This field is required.
Yes
No
N/A - Male
12
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
Yes
No
N/A - Male
13
Have you been diagnosed with any medical conditions?* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
14
Hidden - Have you been diagnosed with any (other) medical conditions* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
15
Please specify what medical conditions you have been diagnosed with* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc.
16
Are you currently taking any medications or supplements?* This field is required.e.g blood pressure/cholesterol meds, multivitamins, probiotics or prebiotics
Yes
No
17
Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
18
Please specify what medications or supplements you are currently taking* This field is required.If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure
19
Have you been diagnosed with any allergies or intolerances by a doctor or healthcare professional?* This field is required.i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose
Yes
No
20
Hidden - Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.
Yes
No
21
Please specify which allergies or intolerances you have* This field is required.i.e. seasonal, medication, or food allergies, or intolerances to gluten, lactose
22
Phone Number* This field is required.
087/021
1234567
23
Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
24
Would you like to be subscribed to Atlantia's database?* This field is required.If you elect to be part of our database, you may be notified of future studies that Atlantia is undertaking that may be of interest to you. All communications to our database are undertaken in accordance with our Privacy Notice available at: https://atlantiaclinicaltrials.com/privacy-notice.
Yes, Subscribe Me
No, thank you.
25
Consent to mailing list - hidden* This field is required.
26
Where did you hear about the study?* This field is required.
Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
UCC
MTU
27
Consent to Privacy Notice* This field is required.We need your explicit consent to process the personal data collected as part of this form in particular, health data. All personal data relevant to pre-screening for trials is processed in accordance with our Privacy Notice. You can withdraw consent by contacting us at dataprotectionofficer@atlantiatrials.com. Do you consent to Atlantia Food Clinical Trials Ltd. processing the information you have provided in this for the purpose of assessing your eligibility for this trial
28
Score* This field is required.
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Reason* This field is required.
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Form Status* This field is required.
Should be Empty: