Thank you for your interest

Thank you for your interest in the project entitled “Healthy Subject Ajmaline Study.”

 
We now need to check that you are eligible to take part.

 
Below are a list of questions regarding your health and family history. This should take 8 mins to complete.

 
Once you have completed this, the information will be sent to a secure email address which can only accessed by those involved in this study.

 

If you are deemed eligible to take part, you will be sent confirmation of this via email. Further information regarding the study and your participation will then be sent via email or post at your request.
 

If you are NOT deemed eligible for this study, we ensure you that your details will be deleted.

 

Any information you give will be handled in the strictest confidence.

 

Thank you.

Dr Bode Ensam 
Cardiology Research Fellow

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* 1. What is your full name ?

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* 2. Date of Birth (DD/MM/YYYY)

Date / Time

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* 3. Sex

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* 4. What is your ethnicity? (Please select all that apply - you may select more that one)

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* 5. Do you currently suffer from any of the following?

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* 6. Have you ever had an unexplained blackout?

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* 7. Do you have a history of any of the following medical conditions?

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* 8. Please list any medication you may be taking

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* 9. Please list any allergies

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* 10. Is there any family history of cardiac problems in anyone under 50 years of age?

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* 11. Is there any family history of sudden or unexplained death in anyone under 50 years of age?

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* 12. Please provide your email address

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* 13. Please provide a contact telephone number and an appropriate time to call

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50% of survey complete.

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