Knee Pain and Weight Management Clinical Trial Application

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Name *

Email *

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Phone *

Best time to call? *

Date of Birth *

Address *

Address Line 1

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City

State / Province / Region

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Country

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? *

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 18 years or over? *

Is your BMI 27 kg/m² or higher? *

Please use the BMI calculator below to help you answer this question, if required. If you already know your BMI, you can just answer the question above.

Unit of measurement

Height (cm)

Weight (kg)

Height

Feet

Weight (lbs)

Inch

Inches

BMI

Verdict

Do you have osteoarthritis in either of your knees? *

of are cancer,

Do you experience knee pain for at least 15 days in a month? *

Have you experienced knee pain lasting longer than 12 weeks? *

Have you ever undergone, or do you plan to undergo, surgery for the treatment of obesity? *

Do you have type 1 or type 2 diabetes? *

Mounjaro (Tirzepatide)
Ozempic (Semaglutide)

Do you currently take, or have you taken within the last 3 months, a GLP-1 medication? This may have been prescribed by your GP or obtained privately. Examples of GLP-1 medications include Mounjaro (tirzepatide) and Ozempic (semaglutide). *

When did you last take this medication?

Do you have a personal or family history of medullary thyroid carcinoma (MTC)? *

Have you ever undergone, or are you currently awaiting, an organ transplant? *

Do you have any inflammatory conditions, such as rheumatoid arthritis, lupus, ankylosing spondylitis, sarcoidosis, Crohn’s disease, ulcerative colitis, amyloidosis, or fibromyalgia? *

Are you currently enrolled in a clinical trial? *

Do you have a history of cancer within the last 5 years, excluding resected basal cell or squamous cell skin cancer, in situ prostate cancer, and non-invasive cervical cancer? *

Do you have a diagnosis of schizophrenia or bipolar disorder? *