BOLD-HTN Eligibility Survey
Are you currently between the ages of 18-80 years?
Yes
No
Sex at birth
Male
Female
Race
I identify myself as an African American
I do not identify myself as African American
Do you take 3 or more medications to control blood pressure?
Yes
No
Is your blood pressure under control?
Yes
No
I don’t know
Have you had a diagnosis of a heart attack, stroke, or heart failure in the last 6 months?
Yes
No
I don’t know
Do you have atrial fibrillation?
Yes
No
Are you currently undergoing dialysis for kidney disease?
Yes
No
Are you currently using CPAP therapy for sleep apnea?
Yes
No
Have you been diagnosed with cancer or have had remission in the past three years? (Note: with the exception of successfully treated basal cell or squamous cell carcinoma of the skin)
Yes
No
Do you have a problem with alcohol use (abuse)?
Yes
No
Do you use any illicit drugs?
Yes
No
Do you work night shifts?
Yes
No
Do you smoke or use e-cigarettes?
Yes
No
Do you have a Smartphone or a computer/Laptop connected to the internet?
Yes
No
First Name:
Home ZIP code:
Email address:
Phone:
I have read and understand the terms of E-Star BioTech, LLC’s Privacy Policy (https://www.e-star.bio/privacy-policy), and by submitting information that is personally identifiable to me as part of my survey responses, I accept that such information will be handled by E-Star BioTech, LLC in accordance with its Privacy Policy. If I am eligible to participate in the BOLD-HTN study, I consent to have my survey responses, including the personally identifiable information contained in them, shared with clinical trial sites participating in the BOLD-HTN study. I further authorize both representatives of E-Star BioTech, LLC and the clinical trial sites that receive my survey responses to use my personal contact information, as provided in my survey responses, to contact me about the BOLD-HTN study.
I consent to E-Star BioTech, LLC retaining my personal contact information, as provided in my survey responses, to contact me about any future studies. I understand that I may withdraw this consent at any time by contacting E-Star BioTech, LLC at BOLD-HTN@estar.bio, and that upon receipt of such withdrawal, E-Star BioTech will remove my personal contact information from its records.
Submit
