General Information

First name *

Last name *

Suburb *

Postcode *

Best Contact Number *

Email *

Date of birth *

Age:

Health History

The following questions about your health will help inform our clinical team of your potential eligibility for current and future trials. We appreciate you help by completing this section of our questionnaire to the best of your ability. Any information you share in this form will be stored securely and kept strictly confidential in accordance with applicable privacy laws and regulations.

Have you ever had any of the following? *

Heart AttackStroke or Transient Ischaemic AttackStent (a small tube inserted to open a blocked artery) or Coronary RevascularisationCoronary Artery Bypass Graft (CABG)None of the aboveUnsure

Which type of diabetes have you been diagnosed with?

Type 1Type 2Unsure

What type of cancer(s) have you been diagnosed with in the last five years?

Skin cancer (not melanoma)MelanomaOther

Have you had your lipoprotein(a) tested? (this is a special cholesterol test - most people haven't had it) *

YesNoUnsure

Lipoprotein(a) result (if known):

Have you had an angiogram in the last five years? (A procedure where dye is used to check blood flow in your heart) *

Are you taking any of these medications? *

High blood pressure medicationCholeserol lowering medications (ie. a statin)GLP1 (ie. Ozempic, etc. for weight loss or diabetes)InsulinI'm not taking any of these medicationsUnsure

Do you smoke (currently)? *

YesNo

Are you currently receiving treatment in another clinical trial? *

YesNoUnsure

Consent

I have read and agree to the Clinitrials Privacy Policy and I consent to being contacted by Clinitrials about trials I may be eligible for. *

By signing below, I confirm the above information I have provided is true, complete and accurate to the best of my ability.

Signature

Draw signature|Type signatureClear

Date *

Your information is stored securely and will only be used to assess your eligibility for Clinitrials studies.

Save and Complete Later