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Dear Participant in IMM Clinical Trials:

As mentioned in our invitation letter, you are invited to participate in our clinical trial on fatigue to evaluate the product, ATP Fuel. To determine if you qualify for participation in this clinical trial, please complete the survey by clicking on the Continue button below. Approximately 100 people will be asked to complete the questionnaire. The survey will take approximately five to ten minutes to complete.

If you have questions at any time about the survey or the procedures, you may contact the trial coordinator, Elaine Hyatt at 949-474-0667 or by email at [email protected].

Thank you very much for your time and support. If you cannot take the survey now but would like to take the survey later, click "Save Page and Continue Later."

Please start the survey now by clicking on the "Continue" button below.

Sincerely yours,

Elaine Hyatt
Research Coordinator
The Institute for Molecular Medicine
Phone: 949-474-0667
Email: [email protected]
 
Contact Information
* First Name : 
* Last Name : 
* Address 1 : 
   Address 2 : 
* City : 
* State : 
* Zip : 
* Phone : 
* Email Address : 
 
 
* Gender
 
 
 
* Birth Date
 
 
 
* Today's Date
 
 
 
* Do you use stimulants (drugs or natural stimulates like caffeine), drink energy drinks, or take sleeping pills?
 
 
* How many glasses of alcoholic beverages do you drink per day?
 
 
* How many cups of coffee do you drink per day?
 
 
* Are you on any anti-depressants?
 
 
* Have you taken any dietary supplements containing NT Factor or NADH within the last 2 months?
 
 
* Have you ever had a diagnosis from a physician for (check all that apply)?
 
Coronary Heart Disease
 
Stroke
 
Diabetes (active)
 
Cancer (active)
 
Neurological Disease (Alzheimer's Disease, ALS, MS, Parkinson's Disease, etc.)
 
Depression (enough to take drugs)
 
Autoimmune Disease (Rheumatoid Arthritis, Sjorgren's Syndrome, etc.)
 
Chronic Fatigue Syndrome
 
Other Fatiguing Illnesses
 
None

 
 
 
* If accepted into this trial, are you able to take a dietary supplement in pill form twice a day (total of 10 pills per day) for sixty consecutive days?
 
 
 
* If accepted into this trial, will you be able to fill out a 22-question survey on days 0, 7, 30 and 60 of the trial using an internet connection?
 
 
 
* Is the address you gave above your shipping address? If not, please supply a shipping address below.
 
 
 
* 1. To what degree is the fatigue you are feeling now causing you distress?
 
0 - No distress
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal of distress
 
 
 
* 2. To what degree is the fatigue you are feeling now interfering with your ability to complete your work or school activities?
 
0 - None
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal
 
 
 
* 3. To what degree is the fatigue you are feeling now interfering with your ability to visit or socialize with your friends?
 
0 - None
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal
 
 
 
* 4. To what degree is the fatigue you are feeling now interfering with your ability to engage in sexual activity?
 
0 - None
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal
 
 
 
* 5. Overall how much is the fatigue, which you are experiencing now, interfering with your ability to engage in the kind of activities you enjoy doing?
 
0 - None
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal
 
 
 
* 6. How would you described the degree of intensity or severity of the fatigue which you are experiencing now?
 
0 - Mild
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Severe
 
 
 
* 7. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Pleasant
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unpleasant
 
 
 
* 8. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Agreeable
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Disagreeable
 
 
 
* 9. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Protective
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Destructive
 
 
 
* 10. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Positive
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Negative
 
 
 
* 11. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Normal
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Abnormal
 
 
 
* 12. To what degree are you feeling:
 
0 - Strong
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Weak
 
 
 
* 13. To what degree are you feeling:
 
0 - Awake
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Sleepy
 
 
 
* 14. To what degree are you feeling:
 
0 - Lively
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Listless
 
 
 
* 15. To what degree are you feeling:
 
0 - Refreshed
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Tired
 
 
 
* 16. To what degree are you feeling:
 
0 - Energetic
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unenergetic
 
 
 
* 17. To what degree are you feeling:
 
0 - Patient
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Impatient
 
 
 
* 18. To what degree are you feeling:
 
0 - Relaxed
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Tense
 
 
 
* 19. To what degree are you feeling:
 
0 - Exhilarated
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Depressed
 
 
 
* 20. To what degree are you feeling:
 
0 - Able to concentrate
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unable to concentrate
 
 
 
* 21. To what degree are you feeling:
 
0 - Able to remember
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unable to remember
 
 
 
* 22. To what degree are you feeling:
 
0 - Able to think clearly
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unable to think clearly
 
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