• 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.

  • LE250801 Phase 2a - The Asthma Study

  • Birth Date*
     - -
  • Format: 0000000000.
  • Biological Sex at Birth*
  • Preferred Pronouns*
  • Date
     - -

  • 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!

  • Your health and medical history

  • Have you had a documented diagnosis of asthma for at least 12 months?*
  • Have you been taking a stable dose of maintenance medication/s for asthma for at least the last 2 months?*
  • Have you had any changes to your asthma therapy in the last 6 weeks?*

  • 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?
  • Are you willing to follow one of the following effective contraception methods from screening and for a minimum of 90 days after dosing on the trial?*

  • 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 from screening and for a minimum of 90 days after dosing on the trial?*

  • 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

  • Other than asthma medication, are you currently taking any other medications, vitamins, or supplements, including stable prescription and over-the-counter options, or those used as needed (e.g. iron supplements)?*
  • Have you taken any prescribed medications that you have started, stopped or changed in the last 1 year or do you plan to make any changes to your prescribed medications?*
  • Other than asthma, 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.)*

  • Your health and medical history

  • Have you ever undergone any surgeries in the past, or do you have planned surgery?*
  • Do you have any current allergies or intolerances, and have you had any allergies or intolerances in the past (i.e. during childhood?)*
  • Have you previously had abnormal blood results from a blood test? For example; low iron or high bilirubin?*
  • Are you a current or former smoker? This includes any tobacco or nicotine-containing products such as vaping shisha, patches and gum.*
  • Have you used illicit drugs in the last 6 months or have you been diagnosed with a substance abuse disorder in the last 2 years?*
  • Do you have any history of clinically significant pulmonary conditions such as chronic bronchitis, emphysema, active tuberculosis or pulmonary fibrosis?*
  • I confirm that I have the time to attend all required sessions and follow-up appointments for this study. I understand that full participation is important, and I agree to follow the study schedule. I have no upcoming travel or work plans, in or outside of Perth, that would stop me from attending the follow-up visits.*

  • Tell us about you

  • What best fits your current lifestyle?*
  • Your preferred study duration for future studies:*
  • Should be Empty: