Blueberry Immune Study Form | School of Public Health

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number - Cell

Preferred method of Contact

Gender

Date of Birth

Height

Weight

The following information is needed to properly assess your qualification to participate in the Blueberry Immune Study conducted by Loma Linda University and will be used per Study Protocol guidelines.

Have you had a flu shot in the past six months?

If yes, please provide the date of the flu shot.

Have you had any other vaccinations in the last three months?

If yes, please provide the date of the vaccination

Do you have any auto- immune disease like Lupus, Rheumatoid Arthritis, Hashimoto Disease etc.

Do you have any severe liver and/ or kidney disease?

Are you diabetic?

Are you taking any weight loss medication?

Are you allergic to berries?

If not allergic to berries, how often do you eat them?

Upon reviewing the information you provided, we will inform you of your eligibility to attend our study information session which is the next step in the process to identify eligible participants. In order to reach you with this information, please indicate the best times to reach you:

How did you learn about the study?

Email from the Research Team

Trading Post

Drayson Center / Other University Avenues

Church

Word of Mouth

Media

Other