Seniors Study | Expression of Interest

This form should take about 3–5 minutes to complete. All information you provide will be kept confidential and used only to evaluate your eligibility for present or future research studies.
LE250304 - Respiratory Health Study
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
Phone Number*
Please enter a valid phone number.
Biological Sex at Birth*

FemaleMale
Preferred Pronouns*

She/HerHe/HimThey/ThemOther
Age (automatically calculated)
Date

DayMonthYear
Date
How Tall are You?*
Height in centimetres
What is Your Current Weight?*
Weight in kilograms
BMI (automatically calculated)
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!
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Contraception methods
We'll now ask some basic questions about your health and lifestyle.

Please answer honestly, as this helps us assess your eligibility and ensures your safety. Your health, privacy and safety are of the utmost importance to Linear.
Are you currently pregnant or breastfeeding, or are you planning to conceive or breastfeed during the trial?

NoYes, I am pregnantYes, I am breastfeedingYes, I am trying to conceive
Female To protect your health and the integrity of our research, we require effective contraception options during the trial. This ensures the medication doesn't affect a potential pregnancy.
There are several reliable contraception methods to choose from. Please consult with your GP for personalised advice prior to screening. The decision to commence any form of contraception should be a decision between you and your GP

Effective Options:
For your information, these methods are not considered reliable during the study:
Do you still experience a menstrual period?*

YesNo
Are you willing to follow one of the following effective contraception methods while participating in the trial from 30 days prior to the start of this trial, throughout the trial, and for a minimum of 90 days after completing the trial?*

YesNo
To protect your health and ensure the integrity of our research, effective contraception is required during the trial to prevent potential pregnancy-related risks. We recommend speaking to your GP for personalised advice before screening.

Acceptable contraception options include:
- Combined methods: Condoms and a reliable female method (e.g. hormonal pill/implant, IUD, tubal ligation).
- Surgical methods: Sterilization (for you or your partner), such as hysterectomy, vasectomy, bilateral salpingectomy, bilateral oophroectomy, tubal ligation, tubal occlusion.
- Abstinence: No opposite-sex sexual activity for at least 2 months before and after the study.
- Partner is post-menopausal: No periods for at least 1 year.
- Same-sex partner(s).
Not acceptable:
- Relying only on condoms
- Withdrawal method
- Emergency contraception ("morning after pill")

Your health and medical history
Are you currently taking any medications, vitamins, or supplements, including prescription and over-the-counter options, or those used as needed (e.g., inhalers, iron supplements)?*

YesNo
Please provide details of the medication/s (e.g. name of the medicine, vitamin, supplement, date first prescribed, and what the medication is treating):
Have you taken prescribed medication that you have ceased in the last 30 days?*

YesNo
Please provide details of the medication/s (e.g. name of prescription medicine, date first prescribed, date stopped or if ongoing and what the medication is treating):
Do you have any current or past medical conditions? **This includes anything that required hospital stays, surgery, regular medication, or specialist visits for heart, liver, stomach, thyroid, mental health, lung, blood, hormone, immune, or metabolic problems**.*

YesNo
Please provide more information (e.g. name of your medical condition, when the condition started, any treatment you had/are receiving):

Your health and medical history
Have you ever undergone surgery, or do you have planned surgery?*

YesNo
Please list the surgery including the procedure date:
If possible, please include the approximate date of the surgery
Do you have any current allergies or intolerances, and have you had any allergies or intolerances in the past (i.e. during childhood?)*

YesNo
Please list the allergies or intolerances:

LE250304 - Respiratory Health Study

Contraception methods

Your health and medical history

Your health and medical history

Your health and medical history

Tell us about you