Human Clinical Trials

Clinical Trial Potential Subject Questionnaire

Setting up a subject profile will allow us to better determine your eligibility to participate in trials that you express an interest in. All information collected is confidential and will not be shared with other organizations. Once you have filled in your information, please have a look that the trials we are now recruiting for on our Current Studies page. If you find one that interests you, call (519) 341-3366, or 1-866-216-8943, or send an email to ccockerline@nutrasource.ca indicating your interest. To sign up as a participant, you should live in or around the Guelph/Kitchener-Waterloo/Cambridge, Ontario area.

In order to update your profile, use the same email address that you initially applied with.

Contact Information

Name:
Email:
Street:
City:
Postal Code:
Phone:

General Health Questions

Do you consider yourself healthy? Yes No
Do you have, or have you ever had, any of the following conditions or diseases:
CancerHigh blood pressure
DiabetesHigh cholesterol
Gastro-intestinal disordersOverweight or obese
Heart diseaseThyroid problems
Do you take any medications or supplements? Yes No

If so, please list the medications and/or supplements (including vitamins, minerals, herbal supplements, fish oils, etc.) you take
on a regular basis.

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