Personal Details Form v2.0 30Sep22

Personal Details Form

Thank you so much for attending this screening appointment! You are one step closer to contributing to medical research which could potentially save lives. Please fill in as much information as you can below. If there is anything that is not applicable then feel free to leave it blank.
Name (as it appears on your photo ID)

Please do not abbreviate your given name
Given Name*
Middle Name*
If you do not have a middle name, type a "-"
Family Name*
Preferred Name
Gender*
Birth and Language Details
City/Town of Birth
Date Of Birth - Day*
Day
Month*
Month
Year*
Year
Current Address
Street Address*
Suburb*
Contact Details
Mobile Number*
Email*
Emergency Contact
Name*
Relationship*
Street Address
Suburb/City
Mobile*
Doctor/GP Clinic Details
Doctor's Name
Clinic Name
Suburb/Town
Medical History
Diabetes Type 1

yesno
Diabetes Type 2

yesno
High Blood Pressure

yesno
Asthma

yesno
Hepatitis A

yesno
Hepatitis B

yesno
Hepatitis C

yesno
HIV

yesno
Gastrointestinal Disorder

yesno
Mental Illness

yesno
Anxiety

yesno
Epilepsy

yesno
Liver Problems

yesno
Psoriasis

yesno
Rheumatoid Arthritis

yesno
Do you have Osteoarthritis?

yesno
Are you Postmenopausal?

yesno
Did you receive the Participant Information & Consent Form (PICF) via email before this visit?

yesno
Consent Agreement:

As a potential participant in a clinical trial run by Linear Clinical Research, we will need to collect some of your personal information, such as contact details and health information, to help us protect your health and safety, and enable us to communicate with you.

A full description of the information that we may collect from you, how we may use it, and your right to access it, is described in our Privacy Policy for Clinical Trial Participants. This is freely available on our website or upon request.

Do you consent to Linear Clinical Research keeping and maintaining your personal information on our database, in accordance with the Australian Privacy Principles, for clinical trial recruitment purposes?
I have read the Information and give my voluntary consent to the use of my personal information for medical research as described therein.*

YesNo
I give permission for my details to be retained so that I can be contacted for future trials*

YesNo
Feedback
I do not wish to provide feedback

Comments

Comments
What is your motivation to participate in a clinical study at Linear?
How will you be arriving to your screening appointment?

DrivingPublic TransportUberOther
Would you have preferred to attend your screening on the weekend or in the evening instead?

No, this time was fantasticYes, an evening time would have suited me betterYes, the weekend would have suited me betterOther
Date

DayMonthYear
Date
Did you know you can receive an extra $250 voucher for referring a friend to Linear?

If you know someone who would be an ideal candidate to help medical research and get paid, tell them to apply for a Linear study! If:
- You fill out you the Refer a Friend Form found on our website
- Your friend is a new applicant
- and if they get dosed on a study...
...then you will receive a $250 voucher as a part of Linear's refer a friend program as our way of saying thank you for spreading the word! (Terms + conditions apply).
Should be Empty:

Personal Details Form

Name (as it appears on your photo ID)

Birth and Language Details

Current Address

Contact Details

Emergency Contact

Doctor/GP Clinic Details

Medical History

Feedback