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  2. 2005
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Thank you for your interest in our study. The following is a brief explanation of the study and a screening form that will be used to determine whether you qualify to participate. Feel free to contact us (303-492-2485) with any questions you may have.

The research study is designed to look at the effects of weight loss on your blood vessels. If you decide to participate you will be assigned to a weight loss or control group. The weight loss group will take part in 12 weeks of diet-induced weight loss. The control group will not change their diet or physical activity habits for the 12 weeks. If you are placed in the weight loss group you will be taught how to change your diet. The goal is to reduce the fat and calories to lose 10% of your body weight in 12 weeks. You will be given a diet plan and daily meals to meet your weight loss goals and gain proper nutrition. This will require you to visit the testing center several times per week to pick up your meals. After testing is complete the control group will be able to be in a similar weight loss program. After completing the intervention you will one again participate in tests 3,4,5,6 (see attachment).

Benefits from the study:
You will receive information regarding your aerobic fitness (VO2max test), bone mineral density, %body fat, dietary intake, blood lipids and blood pressure. In addition, you will receive information regarding your cardiovascular health by having your arteries imaged and by performing a physician-monitored exercise test.
Along with the medical information you will receive $660 if you complete the study. If you decide not to complete the study you will be compensated for the tests you complete.
 
 
 
Name:
   
Home Phone:
   
Work Phone:
   
Cell Phone:
   
Address:
   
E-mail:
   
Emergency contact:
   
Approximate height:
   
Approximate weight:
   
Gender:
   
Age:
   
Date of Birth:
   
Are you right or left handed?
   
Ethnicity:
   
Occupation:
   
 
 

Are you willing to fast overnight?
Yes No
 

Are you comfortable with needles/blood?
Yes No
 

Do you have a history of fainting?
Yes No
 

Do you have any orthopedic problems that would prevent you from walking on a treadmill for 10 to 12 minutes?
Yes No
 

Can you tolerate lying on your back quietly in a bed for up to 4 hours?
Yes No
 
 
What days are you available for testing?
   
How did you hear about the study?
   
 
 
 
Are you currently using tobacco?
   
If not, have you ever used tobacco in the past?
   
If so, how long ago did you quit?
   
 
 
Are you regularly exposed to second hand smoke? (at home, work, bars, restaurants)
   
If so, about how many hours per week?
   
 
 
Do you drink alcohol?
   
If so, how many times per week?
   
 
 
Previous stress test?
   
If yes, what were the results?
   
 
 
Please list any medications you are currently taking (prescription and over the counter):
   
Please list any supplements you are currently taking:
   
 
 

Do you have known high blood pressure?
Yes No
 

Do you have known high cholesterol?
Yes No
 

Do you have known kidney disease?
Yes No
 

Do you have known diabetes?
Yes No
 

Do you have known thyroid disease?
Yes No
 

Do you have known asthma?
Yes No
 
 
 
What is your resting BP?
   
 
 
Have you had your thyroid tested within the last 6 months?
   
If yes are you taking any medication for it e.g., synthroid, thyroxin?
   
 
 
Has your weight been stable over the last 6 months?
   
If No Please Explain
   
 
 
Have you had any recent bacterial infections?
   
Have you had major surgery in the last 6 months? If so, what type and when:
   
 
 

Do you have diagnosed cardiovascular disease?
Yes No
 

Do you have a family history of premature sudden death, heart disease or respiratory problems?
Yes No
 

Do you have a family history of obesity, thyroid or endocrine disorder?
Yes No
 

Do you have surviving relatives with heart disease?
Yes No
 

Do you have a personal history of a heart murmur?
Yes No
 

Do you ever suffer excessive fatigue?
Yes No
 

Do you ever feel light headed or faint when you exert yourself?
Yes No
 

Do you ever feel chest pain when you exert yourself?
Yes No
 

Do you ever feel excessive shortness of breath when you exert yourself?
Yes No
 
 

QUESTIONS FOR WOMEN ONLY:

Menopause Status
Pre Peri Post
 
 
If pre-menopausal: Do you have regular cycles?
   
Are you using oral contraceptives?
   
Are you pregnant or trying to become pregnant?
   
Are you lactating?
   
 
 
If postmenopausal: How long have you been?
   
Was this natural or surgical?
   
Have you ever been on hormone replacement therapy?
   
If yes, when did you start?
   
What type were/are you on?
   
Are you still on hormone therapy?
   
 
 
 
Please describe the type of physical activity you do on weekly basis. List the number of days per week you engage in the activity, how long (min) per session, and what intensity (low, moderate, or hard).
   
 
 

Would you like to be included in our subject registry database?

If your answer is yes, access to this information will be given only to authorized personnel from the following research laboratories: Human Cardiovascular, Locomotion, Neural Control of Movement, Integrative Vascular Biology, and Stress Immunology. There is a possibility that you may be contacted from the above labs at the same time for different projects, however, unnecessary solicitation will be avoided. You are free to withdraw your name and contact information from the subject registry at any time.
Yes No
 
 
 
Additional Comments/Suggestions for improvement
   
 
Please contact [email protected] if you have any questions regarding this survey.
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