Cognition Study

1
Full Name* This field is required.
First Name
Last Name
2
Are you aged between 55-79?* This field is required.This is inclusive of 55 & 79
Yes
No
3
Hidden - Are you aged between 55-79?
Yes
No
4
Are you pregnant, breastfeeding or planning a pregnancy?* This field is required.
Yes
No
N/A - Male
5
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
Yes
No
N/A - Male
6
Are you a smoker or vaper?* This field is required.
Yes
No
7
Hidden - Are you a smoker?* This field is required.
Yes
No
8
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
9
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
10
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.
11
Are you currently taking any medications or supplements?* This field is required.e.g blood pressure/cholesterol meds, multivitamins, probiotics or prebiotics
Yes
No
12
Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
13
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
14
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
15
Hidden - Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.
Yes
No
16
Please specify which allergies or intolerances you have* This field is required.i.e. seasonal, medication, or food allergies, or intolerances to gluten, lactose
17
Phone Number* This field is required.
087/021
1234567
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Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
19
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.
20
Consent to mailing list - hidden* This field is required.
21
Where did you hear about the study?* This field is required.
Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
96FM/C103
Classic Hits
22
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.
23
Score* This field is required.
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Reason* This field is required.
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Form Status* This field is required.
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