First name
Last name
Year of Birth
Gender MaleFemaleOther
City
Postal Code
Email
Phone
Do you have any medical conditions? YesNo
Do you have Diabetes Mellitus Type 2? YesNo
Do you have Cardiovascular Disease (CVD) - Heart or Vessels Disease? YesNo
Do you have Hypertension (High Blood Pressure)? YesNo
Did you have Cerebrovascular Accident (CVA) - Brain Stroke or Hemorrhage? YesNo
Do you have Migraines? YesNo
Do you have Gout? YesNo
Do you have Arthritis? YesNo
Do you have Fibromyalgia? YesNo
Do you have Chronic Pain? YesNo
Do you have Kidney Disease? YesNo
Do you have Thyroid Disease? YesNo
Do you have Anemia? YesNo
Do you have a history of alcohol abuse? YesNo
Do you have Obesity? YesNo
Do you have Male Sexual Health Problems? YesNo
Do you have Depression? YesNo
Do you have Allergies or Asthma? YesNo
If your medical condition is not in this list, please provide it below.
Are you currently taking any medication? YesNo
Do you have any history of smoking? YesNo
Would you like to participate as a healthy volunteer? YesNo
How did you hear about us? (Please specify, i.e. Google search, Facebook ad, etc.)
Can we contact you in the future about studies that may pertain to you? YesNo
