Initial Screening Questionnaire

Are you between 13 and 65 years of age?*
Have you been genetically tested for and diagnosed with Prader-Willi Syndrome (PWS)?*
Do you have, or could you have, a dedicated caregiver at home who has been spending at least 4 waking hours/day with you for a minimum of 5 days a week and will be willing to take part in the study, ie. attend medical center with you and complete questionnaires?*
Do you have diabetes?*
Type I or Type II diabetes?*
Have you ever had a stroke?*
Have you ever been diagnosed with heart disease (e.g., arrhythmia, cardiomyopathy, heart failure, etc.)?*
Are you currently involved in another clinical trial?*

Authorization

By clicking "I agree" below I represent and warrant that I am at least 18 years of age and have authority to give this authorization for the use or disclosure of my personal information, and that there are no restrictions that would prevent me from authorizing the use or disclosure of this information.

-or-

By clicking "I agree" below, I represent and warrant that I am a legal representative of an individual who wishes to be considered as a candidate and have authority to give this authorization for the use or disclosure the individual’s personal information, and that there are no restrictions that would prevent me from authorizing the use or disclosure of this information.


Click here to read the detailed trial authorization. 


Authorization*

Basic Details

Note: If you are completing this questionnaire for a loved one, please use the potential participant's name, not your own name.

Note: Please enter only one email address and one phone number in the boxes below. If you have additional contact information you would like to share, please do so via the "Additional Contact Information"  box.

Follow-Up

Follow-Up

Would you like to receive information on future trials that may be relevant to you?*
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