Cardiovascular Clinical Trial Application

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Nearest Panthera Clinic

Do you consent to the collection and processing of your personal data in accordance with the GDPR for the purposes stated in our privacy policy?

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* To proceed with your pre-screening, we need your consent to collect and process your personal data in accordance with the GDPR. Without this consent, we cannot save your initial data or determine your eligibility, which would result in an incomplete application. Please select 'Yes' to consent. For more information or assistance, contact our team.

Are you aged 55 years or above?

Yes
No

Have you ever had any of the following (Please select any options that apply):

a) Have you ever had an angiogram or been told to have a narrowing in the arteries that supply the heart?
b) Have you ever been diagnosed with Angina Pectoris?
c) Have you ever been told that you have reduced blood supply to your brain (narrowing of the carotid arteries)?
d) Have you ever had a TIA (sometimes called a mini-stroke)?
e) Have you ever had any problems with the circulation to your limbs (called peripheral arterial disease or intermittent claudication)?
f) Have you ever been told you have a diagnoses with Familial Hypercholesterolemia based on genetic testing?

Do you have any of the following risk factors for developing cardiovascular disease (Please select as many options that apply):

Age 65 yrs and above if biologically male or Age 70 and above if biologically female?
Do you suffer from Diabetes?
Do you currently utilise any tobacco products (cigarettes, cigars, tobacco or nicotine containing e-cigarettes)?
Do you suffer from high blood pressure or taking a tablet for high blood pressure?
Do you suffer from high cholesterol or currently taking any medications for high cholesterol?
Has any of your first degree relatives (i.e. parents or siblings) had a heart attack or cardiac bypass surgery before the age of 55yrs (if male i.e. father or brother)/ before the age of 60yrs (if female i.e. mother or sister)?
Have you ever been told you have Kidney Disease

Have you ever had a heart attack, or required stenting or a bypass to your heart?

Yes
No

Have you ever had a stroke or required stenting to the blood vessels in your neck?

Yes
No

Have you ever had a stent inserted to an blood vessels in the legs?

Yes
No

Any history of cancer of any organ system ( excluding skin cancer/ early stage prostate or cervical cancer) within the past 5 years?

Yes
No

Are you currently undergoing kidney dialysis?

Yes
No

Have you ever been diagnosed with HIV, Hepatitis B or Hepatitis C?

Yes
No

Are you currently receiving medications part of another clinical trial?

Yes
No

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