• 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 C - The Breath Study

  • Birth Date*
     - -
  • Format: 0000000000.
  • Biological Sex at Birth*
  • Preferred Pronouns*
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year

  • 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!

  • Smoking

  • 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 a daily smoker of tobacco-containing products (cigarettes, cigars or equivalent) and have been for at least the last 12 months? Please note vaping is not included.*

  • Contraceptive methods

  • Are you currently pregnant or breastfeeding, or are you planning pregnancy within 12 months of the last study drug administration?

  • To protect your health effective contraception is required during the trial to prevent potential pregnancy-related risks. If you are currently pregnant, breastfeeding or planning to during the trial you would not be suitable. We recommend speaking to your GP for personalised advice before screening.

    Please note contraception requirements do not apply to the following groups: 

    • Abstinent: Not sexually active (as your normal lifestyle) with anyone from the opposite sex for at least 2 months before and after the study.
    • Same-sex partner(s)
    • Post-menopausal: No periods for at least 1 year.

    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.

    Not acceptable:

    • Relying only on condoms
    • Withdrawal method
    • Emergency contraception ("morning after pill")
  • Are you willing to follow one of the effective contraception methods from 30 days prior to the start of the trial 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.

    Please note contraception requirements do not apply to the following groups: 

    • Abstinent: Not sexually active (as your normal lifestyle) with anyone from the opposite sex for at least 2 months before and after the study.
    • Same-sex partner(s)
    • Partner is post-menopausal: No periods for at least 1 year.

    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.

    Not acceptable:

    • Relying only on condoms
    • Withdrawal method
    • Emergency contraception ("morning after pill")
  • Are you willing to follow one of the effective contraception methods from 30 days prior to the start of the trial and for a minimum of 90 days after dosing on the trial?*

  • Your health and medical history

  • Are you currently taking any medications, vitamins, or supplements, including prescription or over-the-counter options?*
  • Have you had any changes to any prescribed medications in the last 30 days or do you plan to make any changes?*
  • 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 surgery, or do you have planned surgery?*
  • Do you have any history of severe allergies or anaphylaxis?*
  • Have you previously had abnormal blood results from a blood test? For example; low iron or high bilirubin?*
  • Are you a smoker, or have you used tobacco or nicotine-containing products including vaping shisha, patches and gum within the last 6 months?*
  • 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?*
  • I confirm that I can attend all required sessions and follow-up appointments in the Perth Metropolitan Area (Perth, Western Australia). I understand full participation is required and agree to follow the study schedule. I confirm that I will remain within the Perth Metropolitan Area for the duration of the study and have no travel or work commitments that would prevent my attendance.*

  • Tell us about you

  • Please select your country of birth:*
  • What best fits your current lifestyle?*
  • Your preferred study duration for future studies:*
  • When would you be available to attend a 2-3 hour screening appointment?*
  • What times would suit you best to attend a 2-3 hour screening appointment?*
  • Should be Empty: