LDN and Anti-aging Survey

LDN and Anti-aging Survey
Eligibility
Do you currently take LDN?
In order to complete this survey, you need to be an LDN patient currently taking LDN.
Have you been diagnosed with terminal cancer?
LDN has not been studied for treating terminal cancer. Because of this, we will now end the survey. Please click next to end the survey or just close out the window.
What best describes your naltrexone dosing?
20+ mg of Naltrexone is not considered to be Low Dose. With this being a survey for Low Dose Naltrexone (LDN), and your dosage is considered high dose, the remaining questions will not apply. click Next to end the survey or just close your browser window.

CONSENT
First Name*
Email*

Confirmation EmailConfirm email
What was your sex assigned at birth?*
Please indicate your race-ethnicity(ies). Select all that apply. *
What is your birth year?*
Just enter the year you were born, do not include the month or day.
Are you at least 18 years of age or older? You cannot continue with this survey if you are not.*
You must be 18 to continue. If you are not 18 years of age or older then exit out of this form. No information that was entered will be saved or submitted.
The effects of low dose Naltrexone (LDN) on diseases of aging.

A retrospective cross-sectional study into the off-label use of LDN.

Principal Investigator: Dr. Sajad Zalzala

Institute: LDN Research Trust

Sponsor: Belmar Pharmacy

Email: contact@ldnresearchtrust.org

About:

The study has been reviewed and approved by an institutional review board (IRB): The Institute of Regenerative and Cellular Medicine. Further information can be found at:

https://ircm.org

http://www.fda.gov/RegulatoryInformation/Guidances/ucm126420.html

http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html.

We will investigate any effects of low dose Naltrexone (LDN) on general health and aging-related diseases.

Participation and Eligibility:

Taking part in the study is voluntary and free, and you can withdraw your consent at any time or ask any questions you may have by emailing contact@ldnresearchtrust.org. No payment or reward is given.

Participants must be 18+ years, take Low Dose Naltrexone (LDN) for a diagnosed medical condition, have the legal ability to make your own decisions and complete the questionnaire only once.

Questions will include Information about your health, in the past and present, your medication use, and your family medical history. You could be asked to provide blood test results if available. The tests will look at markers for aging, immune, and general health status.

Participants will not be asked to stop or change the dosing of any your medications, including LDN.

This survey should take you less than 20 minutes to complete

Participants whoare taking LDN 20+ mg per day or have terminal cancer are NOT eligible.

Purpose:

No studies have yet investigated the long-term effects of LDN use, and how it affects the general health of patients taking this medication. We aim to investigate this by assessing the health of patients using LDN for various conditions. We also aim to determine whether LDN use has prevented the use of other medications.

Benefits and Disadvantages:

There are no health benefits. Your contribution could help patients in the future and might lead to a better understanding of the health effects of LDN. There are no health risks in participating.

Confidentiality:

All Information will be stored on JotForm.com. which is password-protected and secured. Your Information will be coded with a unique anonymous identification number. Your anonymous data will be available only to researchers who have approval.

Upon two years of completion, identifiable Information will be deleted, and only the anonymous data will be stored securely. Date
Check each box below to state that you confirm or understand:*
By signing this consent form, you indicate that you have read and understand this consent form, and volunteer to participate in this research study.

You understand that you will receive a copy of this form. You voluntarily choose to participate, but understand that your consent does not take away any legal rights in the case of negligence or other legal faults of anyone who is involved in the study.

You further understand that nothing in this consent form is intended to replace any applicable federal, state, or local laws. You will receive a copy of the, completed, signed and dated form to keep for future reference.
Signature*

Clear
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We greatly appreciate your participation.

If you want to save and continue later to the next section, click on the SAVE button below. You will then get an email with a link to return back to the form. You MUST use that link to return.

If you want to continue to the next section, click NEXT to continue.

Medical History
How long have you been taking LDN?*
How many times a day do you take your LDN?*
What is your most frequently taken daily dose?*
What is your height?*
What is your weight?*
Do you have any medical conditions? Select all that apply.*
Please describe your medical conditions from the previous question.*
Do you currently smoke?*
Please provide as many details as possible (i.e. how long have you smoked for and, on average, how many cigarettes do you smoke per day/week).*
Do any of your immediate family members have a history of any conditions? Select all that apply.*
Please explain your answer from above*
Do you have a history of shingles?*
Provide additional details for your answer above. Such as how long ago did you have Shingles, how long did it last, medications taken for it, and any other information you can provide.*
Do you have a history of cold sore and/or genital herpes outbreaks?*
Please describe in as much detail as you're willing to provide. (How long have you had HSV? How frequently does it flare up? Have you noticed less reactivation while on LDN?) *
Have you had any of the following surgeries? Select all that apply.*
Please describe this surgery.*
Are you on any prescription medications?*
Please list all your medications. For each medication, select the Add Another button to add your next medication.*
Are there any medications that you are taking that are not listed in the above list?
Now for a few questions regarding your experience with LDN.
Approximately what month and year did you begin taking LDN? Be sure to hit the SET button after selecting the month and year. *
Why are you taking LDN?*
What is the other condition for you taking LDN?*
Has LDN allowed you to discontinue, or decrease your dose of, one or more medications?*
Which medications did LDN allow you to discontinue or avoid? How did LDN help? Please share as much detail as you're willing to.*
Has LDN allowed you to avoid any medical procedures?*
Which medical procedure did LDN allow you to avoid? How did LDN help? Please share as much detail as you're willing to.*
Are you willing to share bloodwork?*
Do you have the bloodwork accessible now?*
You may upload your blood work here.

Cancelof
You may upload your additional blood work here.

Cancelof
You may upload your additional blood work here.

Cancelof
Do you have additional bloodwork to upload?*
We greatly appreciate your participation.

If you want to save and continue later to the next section, click on the SAVE button below. You will then get an email with a link to return back to the form. You MUST use that link to return.

If you want to continue to the next section, click NEXT to continue.

Retrospective Quality of Life

For the following questions, please answer with respect to life while taking LDN.
In the year prior to starting LDN, in general, would you say your health was…*
Compared to one year prior to starting LDN, how would you rate your health in general to when you started LDN?*

We greatly appreciate your participation.

If you want to save and continue later to the next section, click on the SAVE button below. You will then get an email with a link to return back to the form. You MUST use that link to return.

If you want to continue to the next section, click NEXT to continue.

Rows	Select from the dropdowns below
In the year prior to taking LDN… I seemed to get sick a little easier than other people.
In the year prior to taking LDN… I was as healthy as anybody I know.
In the year prior to taking LDN… I expected my health to get worse.
In the year prior to taking LDN… my health was excellent.

Rows	Select from the dropdown
In the year prior to taking LDN… to what extent did your physical health or emotional limitations interfere with your social activities like visiting with friends or relatives?
In the year prior to taking LDN… how much bodily pain did you have?
In the year prior to taking LDN… how much did pain interfere with your normal work, including both work outside the home and housework?
In the year prior to taking LDN… did you feel full of pep?
In the year prior to taking LDN… were you a very nervous person?
In the year prior to taking LDN… did you feel so down in the dumps that nothing could cheer you up?
In the year prior to taking LDN… did you feel calm and peaceful?
In the year prior to taking LDN… did you have a lot of energy?
In the year prior to taking LDN… did you feel downhearted and blue?
In the year prior to taking LDN… did you feel worn out?
In the year prior to taking LDN… were you a happy person?
In the year prior to taking LDN… did you feel tired?
In the year prior to taking LDN… did you feel tired?
In the year prior to taking LDN… how much of the time did your physical health or emotional limitations interfere with your physical activities like visiting with friends or relatives?

Quality of Life

For the following questions, please answer with respect to life while taking LDN
In general, would you say your health is...*
Compared to one year ago, how would you rate your health in general now? Would you say it is…*
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
During the past four weeks, how much bodily pain have you had?*

Please select the best answer to the following questions.*

Rows	Select from dropdown below
During the past four weeks, how much time did you feel full of pep?
During the past four weeks, how much time have you been a very nervous person?
During the past four weeks, how much time have you felt so down in the dumps that nothing could cheer you up?
During the past four weeks, how much time have you felt calm and peaceful?
During the past four weeks, how much time did you have a lot of energy?
During the past four weeks, how much time have you felt downhearted and blue?
During the past four weeks, how much time did you feel worn out?
During the past four weeks, how much time have you been a happy person?
During the past four weeks, how much time did you feel tired?
During the past four weeks, how much of the time has your physical health or emotional limitations interfered with your physical activities like visiting with friends or relatives?
During the past four weeks, how much did pain interfere with your normal work, including both work outside the home and housework?
During the past four weeks, how much time has your physical health or emotional limitations interfered with your social activities like visiting with friends or relatives?

LDN prescriberPharmacyLDN Research TrustFriend/Family/ CarerSocial Media
Please provide the name of the person or business that referred you to this survey.*

Thank You!!!

We greatly appreciate your participation.

You have reached the end of the survey.

Clcik the SUBMIT button to submit the survey.
Should be Empty:

Rows	1 Year before taking LDN	Since Taking LDN
For vigorous activities, such as running, lifting heavy objects, or participating in strenuous sports - did your health limit you?
For moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf - does your health limit you?
For light activities, such as lifting or carrying groceries - did your health limit you?
For climbing several flights of stairs - did your health limit you?
For climbing one flight of stairs - did your health limit you?
IFor bending, kneeling, or stooping - did your health limit you?
For walking more than one mile - did your health limit you?
For walking several blocks - did your health limit you?
For walking one block - did your health limit you?
For bathing or dressing yourself - did your health limit you?

Rows	1 Year Before Taking LDN	Last 4 weeks since taking LDN
Did you have to cut down on the amount of time you spend on work or other regular daily activities as a result of your physical health?
Did you accomplish less than you would like as a result of your physical health?
Were you limited in the kind of work or other regular daily activities you do as a result of your physical health?
Did you have difficulty performing work or other regularly scheduled activities as a result of your physical health?
Did you have to cut down on the amount of time you spend on work or regular daily activities as a result of any emotional limitations, such as feeling depressed or anxious?
Did you accomplish less than you would like as a result of any emotional limitations, such as feeling depressed or anxious?
Did you not work or do other regular daily activities as usual as a result of any emotional limitations, such as feeling depressed or anxious?

Rows	Prior to taking LDN	The past 6 months since taking LDN
Sudden High Fever
Diarrhea
Headache
Skin Problems (e.g. acne & eczema)
Muscle and joint pain
Common Cold
Coughing

Rows	Select from dropdown below
I seem to get sick a little easier than other people.
I am as healthy as anybody I know.
I expect my health to get worse.
My health is excellent.

LDN and Anti-aging Survey

Eligibility

CONSENT

The effects of low dose Naltrexone (LDN) on diseases of aging.

A retrospective cross-sectional study into the off-label use of LDN.

Medical History

Retrospective Quality of Life

Quality of Life