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- About Q-Pharm
- Our Leadership Team
Capabilities
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Participate in a trial

About
- About Q-Pharm
- Our Leadership Team
Capabilities
Services
Facilities
News
Contact
Participate in a trial

Participant Registration

CONTRIBUTE TO MEDICAL RESEARCH AND BE REIMBURSED FOR YOUR TIME.

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Step 1 of 3

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Name*
First Last
Mobile Phone*
Email*
Are you able to stay for at least two consecutive days & nights at our centre in Brisbane?*
- Yes
- No

What is your biological sex?*
- Male
- Female
Do you currently use any nicotine-containing products (i.e. cigarettes, cigars, tobacco, vaping)?*
- Yes
- No
How many cigarettes or equivalent nicotine containing products do you smoke?*
- Less than 5 per week
- Less than 5 per day
- Between 5 and 10 per day
- More than 10 per day
Do you regularly use any recreational drugs? (e.g. marijuana, cocaine, ecstasy)*
- Yes
- No
What is your date of birth?*
How tall are you? (In centimeters - e.g. 170)*
How much do you weigh? (in kilograms - e.g. 90)*
BMI

What is your ethnicity or family history?
Are you sexually active with a partner/partners of the opposite sex?*
- Yes
- No
We have strict contraception requirements for our studies because we need to ensure that your partner does not become pregnant during your study participation. During the study, are you willing to adhere to one of the contraception options below?*
- Yes
- No
- Using a condom + your female partner(s) using birth control
- You or your partner(s) had a vasectomy/hysterectomy
- Your partner(s) are post-menopausal
- Abstinence
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We have strict contraception requirements for our studies because we need to ensure that you do not become pregnant while the study medication is in your system. During the study, are you willing to adhere to one of the contraception options below?*
- Yes
- No
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- You using birth control + your male partner(s) using a condom
- You or your partner(s) had a hysterectomy/vasectomy
- You are post-menopausal
- Abstinence
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Do you have any severe allergies? (e.g. anaphylaxis)*
- Yes
- No
Do you have a history of depression or anxiety?*
- Yes
- No
When did you last have treatment for depression or anxiety?*
- More than 6 months ago or never
- Less than 6 months ago or currently
Are you currently taking medication for your depression or anxiety?*
- Yes
- No
Do you have a history of asthma?*
- Yes
- No
What is your asthma status?*
- Childhood asthma
- Asthma more than 5 years ago
- Asthma within last 5 years
- Seasonal asthma
- Current asthma or within the last 6 months
Do you have a history of any other medical or mental health conditions? (e.g. Cancer, Hepatitis, eating disorders, high blood pressure)*
- Yes
- No
Which of the following conditions have you had?
- Cancer
- Coeliac disease
- Diabetes - Type 1
- Diabetes - Type 2
- Epilepsy
- Gastrointestinal problems
- Hepatitis
- HIV
- Liver problems
- Psoriasis
- Rheumatoid Arthritis
- Eating disorder
- Mental health condition
- High blood pressure
- High cholesterol
- Other
If Other, please specify:
Apart from hormonal contraception, are you currently taking any prescription medications?*
- Yes
- No
If the only prescription medication you currently use is hormonal contraception (the pill, a hormonal IUD, contraceptive implant, ...) or PrEP, please select No above
Which prescription medication are you taking?
Are you willing and able to refrain from alcohol, smoking, medication and recreational drugs during the study?*
- Yes
- No
This depends on the study duration, e.g. you might not be allowed to drink alcohol or smoke for two weeks
How did you hear about us?*
- Friends or family
- Facebook or Instagram
- Google
- Another website
- Email
- A Previous study
- Radio
- TV
- Newspaper or magazine
Please enter the name of the person who referred you so they are eligible for a $200 referral bonus.
I consent to Q-Pharm Pty Limited collecting and using my information in accordance with their Privacy Policy.*
- Yes
go You can read our privacy policy here.

Participant Registration
1800 934 320

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