GRYAGE | Screening Form GRYAGE Study Screening and Participant Details "*" indicates required fields We are looking to enrol 65 adults who have light to moderate (10 to 50%) grey hair in the temporal (over the ear) region who are wanting to try a topical herbal product to see if it can reduce the amount of grey hair. The product we are testing is a topical serum applied twice daily to the scalp containing Ageratum conyzoides. Ageratum conyzoides is a herb that grows in tropical and subtropical areas. In previous studies it has been shown to have a beneficial effect on hair growth , but this is the first time it has been tested to see whether it can reduce the number of grey hairs. You will need to attend 4 appointments over a 12 week period at our clinic in Fortitude Valley. Each visit will be conducted by a researcher from RDC Clinical and should take approximately 30-45 minutes. We'll perform some basic medical assessments like blood pressure and pulse rate, ask you to complete a questionnaire and take photos and measurements of your hair and scalp.During your baseline appointment you'll be provided with the topical serum and you'll need to apply a teaspoon of the liquid twice a day, every day for the duration of the study. If you complete the study, you will receive a $200 payment as a thank you for taking part.Trial Coordinators Initials* Participant still interested after study summary?* Yes No Initials of participant that is not interested in continuing to screening... Inclusion/Exclusion CriteriaGender? Male Female Are you aged over 18 years? Yes No Not Eligible Would you describe yourself as generally healthy?We will ask you further specific questions about your health shortly. Yes No Not Eligible Have you participated in any other clinical trial during the past month? Yes Yes, prepared to wait washout period No Not Eligible Do you agree not to participate in any other clinical trials whilst enrolled in this one? Yes No Not Eligible Do you currently suffer from any serious illnesses? (eg. mood disorders such as depression disorder, anxiety disorder or bipolar disorder, neurological disorders such as MS, kidney disease, liver disease, heart conditions) OR any Unstable illness (eg. uncontrolled diabetes or thyroid gland disfunction). Yes - subject has an UNCONTROLLED serious illness No - subject has a CONTROLLED serious illness (if required refer to Dr / PI) No - subject has NO SERIOUS illnesses If any serious illness (uncontrolled OR controlled), please provide details. Not Eligible Are you currently taking Coumadin (Warfarin), Heparin, Dalteparin, Enoxaparin or other anticoagulation therapy including low dose aspirin Yes No Not Eligible Are you currently using topical hair/scalp medication e.g. minoxidil (Rogaine)? Yes No Not Eligible Are there any medications or supplements that you take or use regularly? Yes No Please list any medications or supplements belowNameDoseFrequencyReasonPrescribed? (Y/N) Add RemoveDo you have any history of Cicatricial alopecia, scalp conditions or any other genetic disease or issue that could contribute to baldness? Yes No Not Eligible Are you currently using hair dyes or have you used any in the past 2 months? Yes No Not Eligible Do you believe you have 10-50% grey hair in your temporal region?Please note we will check this as part of your baseline appointment Yes No Not Eligible Do you agree not to change hair products or hair cleansing habits while enrolled in the trial? Yes No Not Eligible Are you able to attend all 4 clinic visits over the 12 week trial period?(Baseline, Week 4, Week 8, Week 12) Yes No Not Eligible Have you had or been treated with cancer in the last 2 years?Basal Cell Carcinoma ok Yes No Not Eligible Do you smoke, use nicotine products or have a history of drug abuse? Yes No Not Eligible Do you regularly drink more than 14 standard alcoholic drinks a week? Yes No Not Eligible If you are a woman of child bearing potential, are you currently using a prescribed form of birth control? Not of child bearing potential Prescribed method of birth control )Oral contraceptive, birth control implant/injection Mirena etc) Abstinence or same sex relationship No highly effective birth control Not Eligible Do you have any known allergies to any of the ingredients in the Study Products? Yes No Not Eligible Screening Result? Passed Failed Need to check Waitlisted Screen Fail, Check, Waitlisted Reason / Notes :Have you informed the participant that we have other studies recruiting that they may be eligible for? Yes No Why not? Did they seem interested in any other studies? Yes No Unsure Participant ID* Thank you for your time on the phone. We will now take a look to see if we can find a time for you to come in for your baseline appointment. Once in the clinic, we will check to make sure your grey hair falls within the 10-50% range we are looking for, if you are found to be outside this range, you may not be eligible to continue. Did you have any questions?
