Participant Disclosure

Research / Study Disclosure

We build a better you.™

You've been selected for a specified 2ndAct Health research or study. Please complete this accurately — full disclosure protects your safety and the integrity of the research/study.

Participant & study details

Full name

Date of birth

Research / study name

Start date

Finish date

Medications currently taken

List every prescription and over-the-counter medication.

Supplements not provided by 2ndAct Health

Only list supplements sourced outside 2ndAct Health.

Other pertinent disclosures

Check any that apply and add detail.

Known allergies or adverse drug / supplement reactions

Recreational substances, cannabis, or alcohol

Pregnant, breastfeeding, or trying to conceive

Recent or planned surgery / hospitalization

Change to any medication or supplement in the last 30 days

Other conditions or products relevant to this research/study

Commitment

I confirm the information above is complete and accurate. Any issues that arise must be reported immediately to preserve the integrity of the above research/study. Any illness that develops during the timeline of the study must be reported immediately. By submitting, I commit to the research/study on the dates specified above.

Type your full name to sign

Thank you

Your disclosure has been sent to 2ndAct Health. You may close this page.