Screening Questionnaire

Any information that you provide, including your name and any other identifying information, will be kept strictly confidential and is secure on our website. You will not be added to any mailing lists.

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First Name *
Last Name *
Which city do you live in?
Male Female
Phone *
Email
Confirm Email
How old are you?
What is your height? ft. in.
How much do you weigh? lbs
How did you first learn of this study?
Do you have Type 2 Diabetes? Yes No Not sure
Do you have Type 1 Diabetes? Yes No Not sure
Have you had any surgical procedures for weight loss? Yes No
Have you gained or lost more than 10Kg (22lbs) in the last 3 months? Yes No Not sure
Have you taken any medication for weight loss in the last 3 months? Yes No
Do you currently use any tobacco (smoking) products or have you in the last 12 months? Yes No
Do you currently use marijuana or drugs or have you in the last 12 months? Yes No
Do you have any alcohol dependency or have you in the last 6 months? Yes No
Do you have any allergies to dairy products, whey, rice, soy or coconut? Yes No Not sure
Do you have an eating disorder? Yes No Not sure
Do you have difficulty swallowing? Yes No
Do you have heart failure? Yes No Not sure
Do you have any other medical problems? (Please describe in space provided)
Which medications and / or natural health products do you currently take on a regular basis?
Are you able to attend 12 study visits in one year, during weekdays? Yes No

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