Asthma Volunteer Application Form"(Required)" indicates required fieldsStep 1 of 210%OK, let's get you startedPlease confirm your email address(Required) What is your full name?(Required) First name Last name Your preferred phone number(Required)(Please enter a valid 11-digit phone number starting with a '0')How did you hear about us?(Required)Choose OneSearch Engine (Google, Bing, etc.)Social MediaEventWord of MouthGP ReferralFriends & FamilyReferralOtherComms Agreement I would like to sign up to FluCamp’s mailing listSubscribe to give us valuable feedback to help improve our services and be invited to exclusive online webinars. Don't worry, we won't spam you!T&Cs Agreement(Required) I have read and agreed to the Terms and Conditions and Privacy Policy(Required)To continue, please make sure you check this box. Before qualifying for a trial we will ask our volunteers GP surgery to share your medical history with our physician team. Please ensure that all questions are answered carefully and correctly.When were you born? Date Of Birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please tell us your genderGender(Required) Male Female Non-binary OtherGender OtherWhich of the following best describes you?Which of the following best describes you?(Required) White (British, Irish, or any other white background) Mixed Ethnicity (e.g., White and Black Caribbean, White and Asian, etc.) Asian or Asian British (e.g., Indian, Pakistani, Bangladeshi, Chinese, etc.) Black, African, Caribbean, or Black British OtherOther Ethnicity(Required)Which screening centre would you prefer?We have two screening hubs located across the UK for you to choose from.As a thank you for your time, you'll receive £40 for your first screening visit.Location Preference(Required) London ManchesterBecome a ReferrerWhen you sign up to FluCamp and attend your first appointment, you will automatically receive your own unique referral code. If you share this with others and they complete a trial, you could receive £250.00Referral T&Cs Agreement(Required) I have read and agreed to the Referral Terms and Conditions(Required)Please read the terms of conditions regarding our referral scheme before moving onto the next step. Volunteers must agree to the terms in order to participate in any trials.Use a referral codeIf one of your friends or family referred you, make sure you ask them for their referral code. If you attend and complete a trial in full, they could receive £250.00 as a thank you for referring you. If you don’t have a code, no worries, simply continue to the next step.Use a referral codeLet's discuss your asthmaKnowing more about how asthma affects you allows us to ensure our trials are safe and suitable for you.Were you diagnosed with asthma more than 6 months ago?(Required) Yes NoHave you been hospitalised for your asthma in the last 3 months?Have you been hospitalised for your asthma in the last 6 months?(Required) Yes NoAre you prescribed an inhaler to manage your asthma?Are you prescribed an inhaler to treat your asthma?(Required) Yes NoAre you prescribed any other medications for your asthma?Are you prescribed any other medications for your asthma?*(Required) Tablets Injections No OtherOther MedicationsDo you have any of the following conditions?You can choose multiple options, but please select at least one.Do you have any of the following conditions?(Required) Cancer Diabetes A neurological condition such as MS or epilepsy An inflammatory condition such as Crohns or rheumatoid arthritis A heart or circulation condition such as hypertension or blood clots A viral blood condition such as HIV or Hepatitis A Issues with having blood taken Allergies eczema, or allergic rhinitis COPD Any other medical conditions? NoneOther Conditions(Required)Are you currently taking any medications or have recently stopped taking medication? (Excluding any form of contraception)Are you prescribed any medications?(Required) Yes NoOther Medication Text(Required)Are you currently waiting to be seen by a clinician, awaiting medical results or undergoing ongoing assessments and treatments for a health-related reason?Are you currently waiting to be seen by a clinician, awaiting medical results or undergoing ongoing assessments and treatments for a health-related reason?(Required) Yes NoHiddenAny other illnesses that may affect your suitability for clinical trials?HiddenAny other illnesses that may affect your suitability for clinical trials?(Required) Yes NoHave you experienced or received treatment (medication or therapy) for anxiety, depression or any mental health concerns in the last 12 months?Have you experienced or received treatment (medication or therapy) for anxiety, depression or any mental health concerns in the last 12 months?(Required) Yes NoAre you currently pregnant, or have you been pregnant in the last 6 months?Are you currently pregnant, or have you been pregnant in the last 6 months?*(Required) Yes NoAre you a smoker or have you ever been a smoker or user of any nicotine products?(Includes vaping, nicotine pouches or any nicotine replacement products)Are you a smoker or have you smoked in the last x years?*(Required) Yes NoHeightWhat height are you (in cm)?(Required)Don't know your height in centimetres? Use the converter tool below then type the result here.FeetInchesHeight in CMYour height in CM is:WeightWhat is your approximate weight (in kg)?(Required)Don't know your weight in kilograms? Use the converter tool below then type the result here.StonesPoundsWeight in KGYour weight in KG is:HiddenBMIDo you have a valid Passport or Driving licence?Do you have a valid Passport or Driving license?(Required) Yes No Not surePlease note a valid ID is required to be able to attend FluCamp.Are you registered with a GP in the UK?Are you registered with a GP in the UK?*(Required) Yes NoPlease note being registered with a UK GP is required to be able to attend FluCamp. Register HereSecurityTo make sure we can identify you, please provide a security question.Security Question(Required)Please select one questionChoose oneWhat was the name of your first pet?In which city or town were you born?What is the make and model of your first car?What is the name of the street you grew up on?Security Answer(Required)