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 or high temperature 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 pregnant or planning on becoming pregnant within the next few weeks?

Yes No

Are you breastfeeding or planning on starting during the course of the trial?

Yes No

Do you have myasthenia gravis?

Yes No

Are you currently admitted in hospital?

Yes No

Do you have a specific heart rhythm abnormality called "prolonged QT syndrome" or condition that prolongs the heart QT interval?

Yes No

Have you previously participated in the PRINCIPLE trial?

Yes No

Are you currently taking antibiotics for a recently diagnosed illness?

Yes No

Do you have an allergy to soya or peanuts?

Yes No

Have you had a previous adverse reaction to, or are you currently taking Azithromycin?

Yes No

Are you currently taking any of the following drugs:

Amiodarone
Bromocriptine
Cabergoline
Ciclosporin
Digoxin
Ergotamine
Ergometrine
Hydroxychloroquine or Chloroquine
Methysergide
Sotalol

Yes No

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 v4.5 11-06-2020
REC Number: 20/SC/058, IRAS Number: 281958, EudraCT Number: 2020-001209-22, Chief Investigator: Professor Christopher Butler