Lean Mass Hyper-responder Study Signup

[NOTE to IRB –> This page is a stand in preview for what will be the live sign up form when we have it programmed in.]

General Questions

First Name ______

Last Name ______

Email ______

Date of Birth ______

Age ______

Height (examples: 6’2 or 188cm) ______

Weight (examples: 170lb or 77kg) ______

Waist size (example: 36”) ______

Gender ______

City ______

State ______

Race (to determine ACC/AHA risk calculation)

[_] American Indian or Alaska Native
[_] Asian
[_] Black or African American
[_] Native Hawaiian or Other Pacific Islander
[_] White

Please list your most recent bloodwork (on this current diet) for any of the following

(If any of these did not get tested or you do not know, fill in “n/a”)

Fasting glucose (mg/dL) ______

Hemoglobin A1c ______

TSH (Thyroid Stimulating Hormone) ______

Systolic blood pressure (mmHg) ______

Diastolic blood pressure (mmHg) ______

C-Reactive Protein (CRP) ______

AST ______

ALT ______

Most recent Lipid Panel

When was this test taken? ______

Were you water-only fasted for 12-14 hours before the cholesterol test? If not, write in how long. ______

Total Cholesterol (TC) ______

LDL Cholesterol (LDL-C) ______

HDL Cholesterol (HDL-C) ______

Triglycerides (TG) ______

Last Lipid Panel before starting your current diet

When was this test taken? ______

Were you water-only fasted for 12-14 hours before the cholesterol test? If not, write in how long. ______

Total Cholesterol (TC) ______

LDL Cholesterol (LDL-C) ______

HDL Cholesterol (HDL-C) ______

Triglycerides (TG) ______

List any supplements you take such as vitamins, fish oil, etc

________________________________________________

List any medications you are taking

________________________________________________

Are you currently taking any medications for high blood pressure? [_]Yes [_]No

Are you currently taking any medications for diabetes? [_]Yes [_]No

Are you taking any lipid lowering supplements or medications including statins, red yeast rice, garlic, ezetemibe, berberine, or similar? [_]Yes [_]No

Have you been diagnosed with any of the following

Heart disease? [_]Yes [_]No

Kidney disease? [_]Yes [_]No

Cancer? [_]Yes [_]No

Genetic Familial Hypercholesterolemia? [_]Yes [_]No

Any ongoing inflammatory disorder? (e.g. psoriatic arthritis) [_]Yes [_]No

If you’ve had a Coronary Artery Calcium (CAC) test before, what was the most recent score? (Leave blank if you’ve never had one.)

Are you currently pregnant, breast-feeding, or expect to become pregnant over the next year? [_]Yes [_]No

Do you have a history of smoking? [_]Yes [_]No

Do you have a known allergy to iodinated contrast material? [_]Yes [_]No

Diet and Exercise

What is a ballpark of your average of your daily calories?______

bout how many grams of protein do you typically consume in a day?______

About how many grams of fat do you typically consume in a day?______

About how many grams of net carbs do you consume in a day? (Net carbs = total carbs – fiber)______

In a typical week, about how many hours do you spend doing cardiovascular / aerobic exercise?______

In a typical week, about how many hours do you spend doing HIIT (high intensity interval training) / anaerobic exercise?______

In a typical week, about how many hours do you spend doing weightlifting / resistance training?______

[SUBMIT]