CONFIDENTIAL

All information submitted through this questionnaire is confidential, submitted using SSL encryption, and will be used only for a preliminary determination by Intervene Immune, Inc. of whether or not you are qualified to enter a study or treatment program. Prior to enrollment, you must complete a blood test and also a formal informed consent process including a review of the protocol in consultation with a physician and study investigator.

Please keep in mind that all questions are not necessarily indicative of eligibility.  We are actively trying to provide options for treatment to as many people as possible.  Accurate and comprehensive answers will help our team craft a more responsible and effective treatment regimen that is customized for you.  

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* 1. Full Name

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* 2. Email Address

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* 3. In what country do you live?

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* 4. Mailing address (for sending trial forms and supplies)

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* 5. Date of Birth (MM/DD/YYYY)

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* 6. Height and weight  (These fields accept positive integers only, so please do not use decimals or use any quotation marks to signify inches)

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* 7. Sex

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* 8. What is your ethnicity? (Please select all that apply.)

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* 9. I'm interested in the following treatments or diagnostics (please select all that apply):

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* 10. I would be willing to travel to Southern California at least twice over a period of 12 months to have imaging work, immune system biomarkers, and epigenetic age biomarkers analyzed, and be willing to also visit a blood collection center local to me an additional 5-7 times to have additional blood diagnostics performed.

Please note however that travel is not required at this time for the TRIIM-X trial due to SARS-CoV-2 travel restrictions.  All participants can enroll remotely by telemedicine, and blood collections can be performed at centers local to them anywhere across the U.S.

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* 11. I would be willing to self-administer the study medications, including by subcutaneous injection 4 times a week (if necessary), or have a partner who can do this for me.

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