Cardiovascular Clinical Trial Application 55+

Name

Email

Confirm Email

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date Of Birth

Best time to call

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?

Yes
No

* 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 18 years or above?

Yes
No

Have you had a normal LP(a) test result with Panthera previously?

Yes
No

Have you ever had any one of the following:

A myocardial infarction (heart attack)?
Any stents inserted into the blood vessels that supply the heart?
Heart bypass surgery?
A stroke not caused by bleeding on the brain (ischaemic stroke)?
Any stents or operations on the blood vessels in your neck?
Any blockages in the blood vessels of the leg that required a stent?
Any blockages in the blood vessels of the leg that led to an amputation?
Any blockages in the blood vessels of the leg that required surgery?

Q1 Established

Yes
No

Have you ever had any one of the following:

Have you ever been told that you have blockages in the arteries that supply the heart?
Have you ever been told that you have reduced blood supply in the blood vessels in your neck?
Have you ever had problems with the circulation in your legs (called peripheral arterial disease)?

Q2 Established

Yes
No

Have you ever had any of the following risk factors (need two risk factors to proceed). Select all that apply:

Age ≥ 65 years (male) or ≥ 70 years (female)?
Do you currently smoke tobacco?
Are you prescribed medication for high blood pressure?
Have you ever been prescribed medication for high cholesterol?
Has your father or any of your brothers had a heart attack, heart bypass, or heart stent at 54 years old or younger?
Has your mother or any of your sisters had a heart attack, heart bypass, or heart stent at 59 years old or younger?
Are you prescribed medication for diabetes?
Have you been diagnosed with chronic kidney disease?

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

Yes
No

Are you currently undergoing dialysis?

Yes
No

Have you ever been diagnosed with hepatitis B or hepatitis C?

Yes
No

Have you ever been diagnosed with HIV?

Yes
No

Are you currently pregnant?

Yes
No

Are you currently receiving medication as part of another clinical trial?

Yes
No

Score

By clicking submit, you are confirming that you have read & understood the Privacy Policy