MedEx-UK 2 Study - Screening Survey

Thank you for your interest in the MedEx-UK2 study. Before you join the study, we need to have some information about you to determine your suitability.

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* 1. Please select the appropriate option below to indicate your willingness to participate in the study:

I confirm that I have read and understood the MedEx-UK2 participant information sheet (Newcastle: Click here and Norwich: Click here) and that I am willing to participate in the MedEx-UK2 study. I agree that any data collected may be used for future research in an anonymised form, and only after being approved by an ethics committee, even if I am not selected to participate in the study

I am not willing to participate in the study

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* 2. Please select the appropriate option below:

I agree that personally identifiable data will be shared with a third party outside of the EEA (Survey Monkey) as this is necessary for the study. However, data will be held securely, and access is strictly limited to the research staff, and solely for the purposes of the study. Data will be deleted from the third party server as soon as it is not needed.

I do not agree that personally identifiable data can be shared with a third party outside of the EEA (Survey Monkey).

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* 3. First name:

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* 4. Last name:

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* 5. Email address:

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* 6. Please provide a contact phone number - this may not be used but is required in the event that one of the study investigators needs to contact you. The number will not be passed on to any third party and will be stored in a secure location for the duration of the study

MedEx-UK 2 Study - Screening Survey

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* 1. Please select the appropriate option below to indicate your willingness to participate in the study:

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* 2. Please select the appropriate option below:

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* 3. First name:

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* 4. Last name:

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* 5. Email address:

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* 6. Please provide a contact phone number - this may not be used but is required in the event that one of the study investigators needs to contact you. The number will not be passed on to any third party and will be stored in a secure location for the duration of the study

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

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* 8. Gender