Asthma Volunteer Application Form"(Required)" indicates required fieldsStep 1 of 170%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')Comms Agreement I would like to sign up to FluCamp’s mailing listT&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 boxWhen were you born? Date Of Birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please tell us your genderGender(Required) Male Female Non-binary OtherGender OtherWhich 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 ManchesterWould 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 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 Allergies eczema, or allergic rhinitis Other NoneOther ConditionsAre 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 smoked in the last 6 months?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 license?Do you have a valid Passport or Driving license?(Required) Yes No Not sureAre you registered with a GP in the UK?Are you registered with a GP in the UK?*(Required) Yes NoSecurityTo 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)
