Survey

Platform Randomised trial of INterventions against COVID-19 In older peoPLE - PRINCIPLE

Participant Registration

Screening Form

Thank you for considering participating in the PRINCIPLE trial.
If you have not already read the Participant Information Leaflet you can download it by clicking the link below.

Click here to download the PRINCIPLE Participant Information Leaflet

There is also an illustrated summary of the Participant Information Leaflet that you can download by clicking the link below:

Click here to download an illustrated summary of the PRINCIPLE Participant Information Leaflet

Click here to access translated versions of the PRINCIPLE Participant Information Leaflet

To start your registration, please complete this screening form.

After you have answered all the questions on this form
please click the "Submit" button at the bottom of the page to proceed to your Consent Form

Are you willing to give informed consent for participation in the study?

Yes No

Do you have a new continuous cough, and/or high temperature, and/or a loss of or change in your normal taste or sense of smell, which have been present for less than 15 days?

Yes No

Defined:
A new continuous cough - this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)
and/or
A high temperature - this means you feel hot to touch on your chest or back
(you do not need to take your temperature)

What date did you start to feel unwell with this illness?

- -

Are you feeling almost recovered from this illness (i.e. generally much improved and your symptoms are now mild or almost absent)?

Yes No

Have you had a positive test for COVID-19 infection?

Yes No

What date was this COVID-19 test taken?

- -

Are you unwell with symptoms of COVID-19?
These symptoms may include, but are not limited to, shortness of breath, general feeling of being unwell, muscle pain, diarrhoea and vomiting.

Yes No

What date did you start to feel unwell with this illness?

- -

Are you feeling almost recovered from this illness
(i.e. generally much improved and your symptoms are now mild or almost absent)?

Yes No

Are you aged 65 years old or over?

Yes No

Are you aged 50 to 64 years old with at least one of the comorbidities/conditions listed below?

weakened immune system due to a serious illness or medication (e.g. chemotherapy)
heart disease or high blood pressure
asthma or lung disease
known diabetes
liver disease
stroke or neurological problem

Yes No

Are you aged 50 to 64 years old
and have a body mass index (BMI) at or above 35 kg/m²?

Click here if you need to calculate your BMI

Yes No

Are you able to use an inhaler?

Yes No

Are you currently admitted in hospital?

Yes No

Have you previously participated in the PRINCIPLE trial?

Yes No

Do you have a known allergy to inhaled corticosteroids?

Yes No

Are you currently prescribed corticosteroids by inhaler, by mouth or had a corticosteroid injection in the past month?

Yes No

Do you have any of the following conditions:

Galactose intolerance
Lapp lactase deficiency
Glucose-galactose malabsorption

Yes No

If other, please specify

After you have answered all the questions on this form and clicked "I'm not a robot" below
please click the "Submit" button at the bottom of the page to proceed to your Consent Form

PRINCIPLE Participant Registration v12.0 13-01-2021
REC Number: 20/SC/058, IRAS Number: 281958, EudraCT Number: 2020-001209-22, Chief Investigator: Professor Christopher Butler