LE250702 Part B | The Breath Study

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.
LE250702 Part B - The Breath Study
Name*

First NameLast Name
Email*
example@example.com
Birth Date*

DayMonthYear
Phone Number*
Please enter a valid phone number.Format: 0000000000.
Biological Sex at Birth*

FemaleMale
Preferred Pronouns*

She/HerHe/HimThey/ThemOther
Date

DayMonthYear
Date
Age (automatically calculated)
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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Contraceptive 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 pregnancy within 12 months of the last study drug administration?

NoYes, I am pregnantYes, I am breastfeedingYes, I am trying to conceive
Are you willing to follow one of the following effective contraception methods from 30 days prior to the start of the trial and for a minimum of 224 days after dosing on 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, tubulal occulusion.
- Abstinence: No opposite-sex sexual activity for at least 2 months before and after the study.
- 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")
Are you willing to follow one of the following effective contraception methods while participating in the trial from 30 days the start of this trial, throughout the trial, and for a minimum of 224 days after dosing on 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 stable 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 any prescribed medications that you have started, stopped or changed in the last 30 days or do you plan to make any changes to your prescribed medications?*

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, kidney, stomach, 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):

LE250702 Part B - The Breath Study

Contraceptive methods

Your health and medical history

Your health and medical history

Tell us about you