Gknowmix Test Request


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Section A: Personal Details

Personal Details

E-mail Address
Surname
First Name
Date of Birth
Age
Gender
Postal Address
Postal / Zip Code
Country
Phone (Day Time)
Cell (Mobile)
Receive quote email:
Receive informed consent email:

Section B: Current Sporting Details

Please record your CURRENT sporting and physical activities in order of importance

Please record your CURRENT sporting and physical activities in order of importance

Do you CURRENTLY participate in any sport or other forms of physical activity?

If yes, please select YES below and provide relevant information.

If yes, please select YES below and provide relevant information.

Do you currently participate in any sport or other forms of physical activity?

Current Sports

Type of sport(s) you CURRENTLY participated in (please name)
Year started participation
Years in competitive sport
Professional or amateur
Hours of training per week during the preceding 3 months
Hours of training per week during the preceding 4 to 12 months
Hours of training per week during the preceding 13 to 24 months

Section C: Previous Sporting Details

Please record your PREVIOUS sporting and physical activities in order of importance

Please record your PREVIOUS sporting and physical activities in order of importance

Have you PREVIOUSLY participated in any sport or other forms of physical activity?

If yes, please complete the following form

If yes, please complete the following form

Have you participated in any sport or other forms of physical activity in the past?

Past Sports

Type of sport(s) you have participated in the PAST (please name)
Year started participation
Years involved in the sport
Years in competitive sport
Professional or amateur

Section D. General Personal Medical History

Do you currently suffer from any Connective Tissue, Rheumatological Or Muscle Diseases & Disorders?

If Yes, please select from the list below

If Yes, please select from the list below

Do you currently suffer from any Connective Tissue, Rheumatological or Muscle Diseases & Disorders?

List of some Connective Tissue and/or Rheumatic Diseases and Disorders

Ankylosing Spondylitis Lipid Storage Diseases Pseudogout
Aspartylglycosaminuria (AGU) Marfan Syndrome Reactive Arthritis
Behcet’s Syndrome Menkes Kinky Hair Syndrome Reiter’s Syndrome
Crohn’s Disease Mucopolysaccharidoses Relapsing Polychrondritis
Discoid Lupus Erythematosus Myopathy and Dystrophy Scleroderma
Ehlers-Danlos syndrome (EDS) Ochronosis (Homocystinuria) Sjogren’s Syndrome
Eosinophilic Fascitis Osteogenesis imperfecta (OI) Systemic Lupus Erythematosus (SLE)
Giant Cell (Temporal) Arthritis Osteoarthritis Systemic Sclerosis
Gout Polyarteritis Nodosa Wegener’s Granulomatosis
Hypersentive Vasulatis Polymyalgia Rheumatica Rhabdomyolysis
Polymyositis & Dermatomyositis Other

Age of Onset and diagnosis

Please indicate the age of onset of disease symptoms and age of diagnosis of any of the above conditions

Please indicate the age of onset of disease symptoms and age of diagnosis of any of the above conditions

Age of Onset
Age of Diagnosis

Have you ever used fluoroquinoline antibiotics?

List of some fluoroquinoline antibiotics (may be used in treatment of chlamydia, pneumonia, acute bronchitis, urinary tract infections, skin and soft tissue infection):

ADCO-CIPRIN

AVELON

BACTIDRON

CIFLOC

CIFRAN

CIPLA-CIPROFLOXACIN

CIPLOXX

CIPRO-HEXAL

CIPROBAY

CIPROGEN

CPL ALLIANCE CIPROFLOXACIN

DYNAFLOC

FACTIVE

FLOXIN

MAXAQUIN

NOROXIN

ORPIC

SANDOZ CIPROFLOXACIN

TAFLOC

TARIVID

TAVANIC

TEQUIN

UNIQUIN

UTIN-400

ZANOCIN

 

List of some fluoroquinoline antibiotics (may be used in treatment of chlamydia, pneumonia, acute bronchitis, urinary tract infections, skin and soft tissue infection):

ADCO-CIPRIN

AVELON

BACTIDRON

CIFLOC

CIFRAN

CIPLA-CIPROFLOXACIN

CIPLOXX

CIPRO-HEXAL

CIPROBAY

CIPROGEN

CPL ALLIANCE CIPROFLOXACIN

DYNAFLOC

FACTIVE

FLOXIN

MAXAQUIN

NOROXIN

ORPIC

SANDOZ CIPROFLOXACIN

TAFLOC

TARIVID

TAVANIC

TEQUIN

UNIQUIN

UTIN-400

ZANOCIN

 
Have you ever used fluoroquinoline antibiotics?
When did you last take fluoroquinoline antibiotics?

Section E. Family Medical History

Have any of your blood (biological) relatives ever had the following?

Please tick yes or no. If yes, please tick the relationship of that person to you (You may tick more than one of the relationship blocks).

Have any of your blood (biological) relatives ever had the following?

Please tick yes or no. If yes, please tick the relationship of that person to you (You may tick more than one of the relationship blocks).

Chronic Achilles tendon injury

Chronic Achilles tendon injury

Chronic Achilles tendon injury - Relationship

Father Mother Brother Sister Child Grandfather Grandmother

Achilles tendon rupture

Achilles tendon rupture

Achilles tendon rupture - Relationship

Father Mother Brother Sister Child Grandfather Grandmother

Any other (not Achilles) tendon injury/rupture

Any other (not Achilles) tendon injury/rupture

Any other (not Achilles) tendon injury/rupture - Relationship

Father Mother Brother Sister Child Grandfather Grandmother

Anterior Cruciate Ligament (ACL) injury

Anterior Cruciate Ligament (ACL) injury

Anterior Cruciate Ligament (ACL) injury - Relationship

Father Mother Brother Sister Child Grandfather Grandmother

Any other (not ACL) ligament injury

Any other (not ACL) ligament injury

Any other (not ACL) ligament injury - Relationship

Father Mother Brother Sister Child Grandfather Grandmother

Section F: History of Tendon, Ligament or Joint Capsule Injury

Tendon or Ligament Injury

If YES, then enter the number of injuries (0, 1, 2, etc)

If YES, then enter the number of injuries (0, 1, 2, etc)

Have you ever suffered from a tendon or ligament injury in any tendon or ligaments?

Tendon Injuries

TendonTendinopathy LeftTendinopathy RightAcute Tear or Rupture LeftAcute Tear or Rupture RightAge of Onset
Achilles tendon
Foot and ankle Foot and ankle Tibialis posterior
Plantar fascia
Knee Knee Patellar tendon
Elbow and wrist Elbow and wrist Wrist extensor tendon
Shoulder Shoulder Rotator cuff
Other Other

Ligament Injuries

LigamentSprain LeftSprain RightComplete Tear LeftComplete Tear RightAge of Onset
Shoulder ligaments
Elbow ligaments
Wrist ligaments
Finger ligaments
Knee (ACL)
Knee (MCL)
Knee (PCL)
Knee (LCL)
Ankle lateral ligaments
Ankle medial ligaments
Spinal ligaments
Other

Joint Capsule Injuries

InjuryAge of Onset
Acute shoulder dislocation
Chronic shoulder instability
Chronic ankle instability
Other

Genetic Tests

COL1A1 - G > T
COL5A1 - C > T
COL5A1 - del > AGGG
COL5A1 - ATCT > del
COL5A1 - A > T
MIR608 - C > G
GDF5 - T > C
CASP8 - CTTACT > del
Research Number