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Research
Walnut Immune Study
Walnut Immune Study Screening Form
Walnut Immune Study Screening Form
In this section
Walnut Immune Study
Location
Previous Related Study
Walnut Immune Study Screening Form
name
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cell phone number
email
preferred method of contact
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date of birth
height
height: Feet
feet
height: Inches
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Status message
The following information is needed to properly assess your qualification to participate in the Walnut Immune Study conducted by Loma Linda University and will be used per Study Protocol guidelines.
Have you had any vaccination this year?
- Select -
Yes
No
If yes please provide the date of vaccination
Do you have any auto-immune disease like Lupus, Rheumatoid Arthritis, Hashimoto Disease etc.
Yes
No
Are you allergic to walnuts?
Yes
No
If not allergic to walnuts , how often do you eat them?
Daily
2-3 times a week
1-2 times a week
Rarely
Never
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:
Morning 8:00 AM - 12:00 PM
Afternoon 12:00 PM - 5:00 PM
Evening 5:00 PM - 8:00 PM
How did you learn about the study?
Email from research team
Trading Post
Drayson Center / Other university avenues
Church
Word of Mouth
Media
Other…
Enter other…