Asthma Volunteer Application Form

Step 1 of 20

OK, let's get you started

Please 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?

Comms Agreement

I would like to sign up to FluCamp’s mailing list

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

When were you born?

Date Of Birth(Required)

Please tell us your gender

Gender(Required)

Male

Female

Non-binary

Other

Gender Other

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

Manchester

Would you like to use a referral code?

If one of your friends referred you, make sure to ask them for their volunteer ID number.
When you attend a trial, your friend will receive £500 as a thank you for referring you. If you don't have a code, no worries, simply continue on to the next step.

Referral code

Let's discuss your asthma

Knowing 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

Have 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

Are you prescribed an inhaler to manage your asthma?

Are you prescribed an inhaler to treat your asthma?(Required)

Yes

Are you prescribed any other medications for your asthma?

Are you prescribed any other medications for your asthma?*(Required)

Tablets

Injections

Other

Other Medications

Do 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

Allergies eczema, or allergic rhinitis

Other

None

Other Conditions

Are you prescribed any medications?

Are you prescribed any medications?(Required)

Yes

Any other illnesses that may affect your suitability for clinical trials?

Any other illnesses that may affect your suitability for clinical trials?(Required)

Yes

Have you experienced anxiety or depression in the last 2 years?

Have you experienced anxiety or depression in the last 2 years?(Required)

Yes

Are 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

Are you a smoker or have you smoked in the last 6 months?

Are you a smoker or have you smoked in the last x years?*(Required)

Yes

Height

What height are you (in cm)?(Required)

Don't know your height in centimetres? Use the converter tool below then type the result here.

Feet

Inches

Height in CM

Your height in CM is:

Weight

What is your approximate weight (in kg)?(Required)

Don't know your weight in kilograms? Use the converter tool below then type the result here.

Stones

Pounds

Weight in KG

Your weight in KG is:

Hidden

BMI

Do you have a valid Passport or Driving licence?

Do you have a valid Passport or Driving license?(Required)

Yes

Not sure

Are you registered with a GP in the UK?

Are you registered with a GP in the UK?*(Required)

Yes

Security

To make sure we can identify you, please provide a security question.

Security Question(Required)

Please select one question

Security Answer(Required)