Template | PRE-SCREEN (V2)

Name*

First NameLast Name
Email*
example@example.com
Nice to meet you, {name}!

Your responses will be kept confidential between you and the Linear team in line with our privacy policy. Please continue to check your eligibility to participate in one of our studies in Perth, Western Australia!
Birth Date*

DayMonthYear
Age (automatically calculated)
Biological Sex at Birth*

FemaleMale
Preferred Pronouns*

She/HerHe/HimThey/ThemOther
Phone Number*
Please enter a valid phone number.
Postcode
Date

DayMonthYear
Date
Please confirm:*

I give Linear permission to use this information to confirm my suitability for a screening visit & retain this information to contact me for future trials. I confirm that the information that I will provide is correct.
Channel
Channel Drilldown 1
Channel Drilldown 2
Channel Drilldown 3
Landing Page
Landing Page Goup

Health and Medical History
Do you currently use any nicotine-containing products or have you used any in the last 6 months (i.e. cigarettes, cigars, tobacco, vaping)?*

YesNo
How many tobacco or nicotine-containing products (includes vaping, shisha, patches and gum) have you used in the last 6 months?
Have you used illicit drugs in the last 6 months, or have you ever been diagnosed with a substance abuse disorder?*

YesNo
On average, how many standard alcoholic drinks would you consume per week?*
Please apply 0 if you do not drink alcohol regularly weekly

Health and Medical History
Have you had any moderate or severe active infection or acute illness (including cold/flu, COVID-19, temperature exceeding 38°C in the last 30 days?*

YesNo
Do you have any tattoos, scarring or birthmarks on the abdomen?*

YesNo
Please provide details:
Are you a night shift worker? (regular working hours between 10:00 pm and 6:00am)*

YesNo
Are you willing to wear an ambulatory blood pressure monitoring (ABPM) device for 24 hours prior to your visit to the study clinic for 5 of the visits during the follow up period?*

YesNo

BMI and Ethnicity