The Information You Provide in This Questionnaire Will Be Used to Determine Your Eligibility

Resistant Starch Study Questionnaire

The information you provide in this questionnaire will be used to determine your eligibility for this study and is not a commitment to participate. The information will be available only to our research staff and will be held in confidential files. No use of this information will in any way identify you as a participant. Please use the enclosed envelope to send your questionnaire to: Cholesterol Research Center, 3101 Telegraph Ave. Berkeley, CA 94705 or Fax: (510) 665-3177.

Name:

Address: City & Zip:

Date of Birth: (Month-Day-Year) Sex:

Phone: ( ) ( ) ( )

Home Work Cell

E-mail: Height: ft in Weight: lb

1. Do you currently smoke? Yes No

2. Have you had or do you currently have cancer, diabetes, liver or renal disease, Yes No

stroke, high blood pressure (>150/90), blood clotting disorders, or other chronic diseases?

If other, please specify

3. Do you take medication for blood pressure, thyroid, diabetes, or cholesterol? Yes No

If yes, please list name of medication(s):

4. Have you had heart disease (myocardial infarction, angioplasty, by-pass surgery)? Yes No

5. What is the most you have ever weighed (excluding pregnancies)? lbs

6. During an average week, how many hours do you spend in aerobic exercise?

Running hrs Cycling hrs Swimming hrs Walking hrs Other hrs

7. a. Ethnicity (circle one): 1) Hispanic or Latino 2) Not Hispanic or Latino 3) Unknown or Decline to State

b. Race (circle all that apply): 1) White 2) Black 3) Native-American 4) Asian

5) Pacific Islander 6) Unknown or Decline to State

8. FOR WOMEN ONLY:

a. Are you post-menopausal (> 1 year since last period)? Yes No

b. Are you currently on hormone replacement therapy? Yes No

c. Are you currently pregnant or breastfeeding? Yes No

9. May we contact you in the future to determine if you are eligible for other studies Yes No

being conducted through the Cholesterol Research Center?

10. Are you currently participating in any other research studies? Yes No

Thank you. If you meet our eligibility criteria for the study, we will call you for an interview.

Informed consent: I understand that this information will remain strictly confidential. I understand that completion of this questionnaire is completely voluntary and that I am under no obligation to participate in the Resistant Starch Study.

Signature: Date:

RS07b Screening Questionnaire v3.1 4/23/10