Condition Form

What is your date of birth? *

Age is a critical factor in clinical research to ensure the safety of participants and the accuracy of study results, as different age groups may react differently to treatments.

Date of Birth *

What is your height and weight? *

This information will be used to calculate your BMI, or body mass index.

BMI helps researchers understand how a treatment might affect individuals with different body types and ensuring the dosage is appropriate.

Feet *

Inches

Pounds *

What is your sex? *

Biological sex can influence the effectiveness and side effects of medications.

Male

Female

Other/Prefer not to answer

Do you have a history of any of the following diagnoses, cardiovascular events, or have you had any heart related treatments? *

Please check all that apply.

Previous cardiovascular events are important for screening to ensure the study protocol safely accommodates your medical history.

Do you have chronic kidney disease? *

Chronic kidney disease (CKD) is a condition where your kidneys lose their function over time.

Kidney function is vital for processing medications. Knowing your CKD status helps determine if the study is safe for you.

Yes No Unsure

Do you have high blood pressure, also called hypertension? *

High blood pressure means a recent reading where the top number was at least 130 or the bottom number was at least 90...

Hypertension is often a primary or secondary condition being studied in cardiovascular research.

Yes No Unsure

Do you have Diabetes? *

If so, which type?

Diabetes status is crucial as many clinical trials for heart and weight focus on glucose management.

Type 1 diabetes

Prediabetes

Type 2 diabetes

Another type

I don’t have diabetes

Have you ever taken a medication containing GLP-1? *

Example: Ozempic®, Wegovy®, Mounjaro®, Zepbound™, etc.

Previous use of GLP-1 receptor agonists can impact your baseline measurements and eligibility for new weight-loss studies.

Yes No Unsure

Have you had any of the following conditions or procedures? *

Certain inflammatory or neurological conditions may interfere with study outcomes or participant safety.

Cancer (past 5 yrs)

Rheumatoid arthritis

Alzheimer’s

Preclinical Alzheimer’s

Mild cognitive impairment

Dementia

Lupus

None of the above

Not including GLP-1 medications, have you ever taken any other weight loss medication? *

To evaluate a new treatment, researchers need to know what other medications you have used that might influence weight.

Yes No Unsure

Have you ever had any of the following surgical procedures for obesity? *

Bariatric surgeries permanently alter the digestive system, which can change how medications are absorbed.

Gastric bypass surgery

Sleeve gastrectomy

Biliopancreatic diversion

Mucosal ablation

Gastric artery embolization

Another surgery

None of the above

Unsure

Have you ever had any device-based procedures for obesity such as Lap-Band®, intragastric balloon, or duodenal-jejunal endoluminal liner? *

Devices like gastric balloons can affect gastric emptying and medication effectiveness.

Yes No Unsure

Would you be able to get your medical records prepared with the help of the study center? *

Verification of medical history through official records is a mandatory step in confirming study eligibility.

Yes No Unsure

Do you consider yourself Hispanic or Latino? *

Click to reveal description

Collecting ethnicity data helps ensure that clinical trials represent diverse populations, which is essential for understanding treatment effects across all backgrounds.

Yes No Prefer not to answer

Which of the following best describes you? *

American Indian

Asian

Black or African American

Native Hawaiian

White or Caucasian

More than 1 option

Prefer not to answer

User Agreement *

By clicking ‘SUBMIT’, I acknowledge that I have read the Privacy Notice and consent to the collection and sharing of my health information.

I agree I don't agree

Candidate Information:

First Name *

Last Name *

Cell Phone Number *

Email Address *

Address *

Zip code *

What is your date of birth? *

What is your height and weight? *

What is your sex? *

Do you have a history of any of the following diagnoses, cardiovascular events, or have you had any heart related treatments? *

Do you have chronic kidney disease? *

Do you have high blood pressure, also called hypertension? *

Do you have Diabetes? *

Have you ever taken a medication containing GLP-1? *

Have you had any of the following conditions or procedures? *

Not including GLP-1 medications, have you ever taken any other weight loss medication? *

Have you ever had any of the following surgical procedures for obesity? *

Have you ever had any device-based procedures for obesity such as Lap-Band®, intragastric balloon, or duodenal-jejunal endoluminal liner? *

Would you be able to get your medical records prepared with the help of the study center? *

Do you consider yourself Hispanic or Latino? *

Which of the following best describes you? *

User Agreement *

Candidate Information:

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What is your date of birth? *

What is your height and weight? *

What is your sex? *

Do you have a history of any of the following diagnoses, cardiovascular events, or have you had any heart related treatments? *

Do you have chronic kidney disease? *

Do you have high blood pressure, also called hypertension? *

Do you have Diabetes? *

Have you ever taken a medication containing GLP-1? *

Have you had any of the following conditions or procedures? *

Not including GLP-1 medications, have you ever taken any other weight loss medication? *

Have you ever had any of the following surgical procedures for obesity? *

Have you ever had any device-based procedures for obesity such as Lap-Band®, intragastric balloon, or duodenal-jejunal endoluminal liner? *

Would you be able to get your medical records prepared with the help of the study center? *

Do you consider yourself Hispanic or Latino? *

Which of the following best describes you? *

User Agreement *

Candidate Information: