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Vitamin E Study Application
Involves 2 - 8 hour testing days and one 30 minute pre-screening session. Blood draw is mandatory.
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Full Name
*
Your answer
Phone #
*
Your answer
Email (enter carefully please)
*
Your answer
Date of Birth (MM/DD/YY)
Your answer
City in Florida that you reside
*
Your answer
How did you hear about the study (if someone referred you please list their name)
Your answer
Gender
Female
Male
Clear selection
Height (Feet' Inches")
Your answer
Weight (current weight in pounds)
Your answer
List All Current Supplements
Your answer
List Diagnosed Medical Conditions
Your answer
List All Current Medications
Your answer
Check all that apply
*
High Blood Pressure
Type 1 Diabetes
Type 2 Diabetes
Cancer
Thyroid disease
Auto Immune Disorders
High Cholesterol
No gallbladder
IBS or IBD
Celiac Disease
Anemia
Vitamin D deficiency (Under 30 ng/ml)
Obese
On blood thinners
None Known
Required
Testing Day One Preference
*
Thursday Oct 28
Friday October 29
Either- I am flexible
Required
Testing Day Two Preference
Tuesday Nov 2
Wed Nov 3
Either. I'm flexible
Clear selection
What is the earliest time you could begin testing on those days? (times from 5:45am on and keep in mind you would be there for 8 hours)
*
Time
:
AM
PM
Any Questions?
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