Panelist Sign Up Form

Participate in Our Studies!

Complete the form below to be considered for our studies. All information provided is protected and private. We do not share your information with anyone outside of ALS.
Today's Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Ethnicity*
Choose the option that best represents your primary ethnicity
Address*

Street Address

Apartment Number

CityState

Post CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
What is your preferred method of contact?*
Closest ALS Facility*
Do you have a reliable form of transportation to get to the testing facility?*
How did you hear about us?*
Who referred you to ALS?*
Please let us know how you heard about us*
Tell us about yourself!
How would you describe your skin?*
What is your skin type?*
Use the image below as a guide for your response
What is your hair type?*
Use the image below as a guide for your response
Is your hair treated?*
What color is your hair?*
Have you had hair restoration procedure(s)*
How would you describe your hair (check all that apply)?*

ThickThinDamagedDryNormalOilyFlatBreaks EasilyHair LossFrizzyGreyDull / Lacks Shine
How would you describe your eyelashes (check all that apply)?*

ShortMediumLongExtra longThickSparseCurlyDense
What is the state of your eyebrows (check all that apply)?*

Sparse growthNatural, fullMicrobladedTattooed
What is the state of your facial hair (check all that apply)?*

ThickFineCoilySparseBeardMustacheStubbleI don't have facial hair
If you have facial hair, are you open to shaving it if needed?*
Do you have dandruff?*
Do you have stretch marks?*
If yes, where?*

ButtocksAbdomenLegsArmsOther
Do you have tattoos?*
If yes, where?*

HandsForearmsBodyFace
Do you have facial piercings?*

Yes, I can remove them if neededYes, but I cannot remove themNo
Is your skin prone to acne?*
Do you wear contacts?*
If yes, what kind?*
Do you have sensitive eyes?*
Do you have sensitive skin?*

How does your skin react to different conditions?*

	Yes	No
Does your skin get dry in the winter?
Does your skin itch when wearing different fabrics?
Does your skin react when you change your personal care products?
Do you have discomfort triggered by temeprature change?
Do you have discomfort triggered by wind?
Do you have discomfort triggered by pollution?
Do you have discomfort triggered by chlorine?
Do you have discomfort triggered by certain personal care products?
Do you have discomfort triggered by certain laundry products?

If you have sensations when using personal care products, how long do they last?*

SecondsMinutesHoursDaysI do not experience any sensations when using personal care products
Do you have children under age 18 that may be considered for pediatric studies?*

Tell us about your health!

Have you even been diagnosed by a physician for the following medical conditions?*

	Diagnosed?	Year Diagnosed	Medcation(s) Taking?
Diabetes Type I
Diabetes Type II
High Blood Pressure
High Cholesterol
Depression / Anxiety
Kidney Problems
Heart Problems
Acne/Pimples
Eczema
Dermatitis
Psoriasis
Rosacea
Asthma
Cancer
HIV / AIDS
Epilepsy / Seizure Disorder
Ulcers
Thyroid Disease
Arthritis
Neurological Problems
Gastroinestinal Problems
Ear/Nose/Throat Problems
Liver Disease
Hepatitis
Lung Disease
Sexually Transmitted Disease
Lupus
Headaches / Migraines
Auto-Immune Disorders
Cold Sores

Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsAdhesivesPenicillinSunscreensSoapsDetergentsCosmeticsAntiperspirantsBath ProductsMedicinesNoneOther
Do you take any of the following dietary / health supplements?*

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinCollagen PowderNoneOther
FEMALES ONLY
Are you taking birth control?*
If yes, what type of birth control are you using?*
Have you had a hysterectomy?*
Have you had a tubal ligation?*
Are you pregnant, nursing, or trying to become pregnant?*
Are you undergoing any hormone replacement therapy?*
Are post-menopausal (at least one year)?*
Do you menstruate regularly?*
MALES ONLY
What is your current shaving system? *

Razor / Wet shaveElectricN/A - I do not shave
Do you experience irritation from shaving?*
Tell us about your lifestyle!
Are you a smoker?*
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)?*
Please rate your stress level*

LowMediumHigh
How would you best describe your working conditions?*
Do you consume alcohol?*
If yes, how often?*

Daily5-6x per week3-4x per week1-2x per weekInfrequently (a couple times per month)
Do you exercise?*
Do you experience trouble sleeping?*
Tell us about your skincare!
Have you received any of these services in the last 30 days?*

Anti-Wrinkle Injections (ex. Botox)Dermal FillersThreadsLaserSkin Treatments / PeelsNone
What Skin Care Products do you currently use (check all that apply)?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)MaskNail Product(s)
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsYes, greater than 3 months agoNo
Do you wax / shave / or use depilatories?*
If yes, where do you shave, wax or use depilatories?*

EyebrowsLegsUpper lipChinIntimate region
Do you have permanent makeup?*
If yes, where?*

EyebrowsEyelinerLips
What type of facial cleanser do you use?*

CreamLiquidGelBar soapBath soapFacial wipesNone - I do not use a facial cleanser
What type of toner do you use?*

AlcoholNon-alcoholMedicatedNone - I do not use a toner
What type of mask do you use?*

Wash offPeel offScrubNone - I do not use a mask
What type of moisturizer do you use?*

LotionCreamGelNone - I do not use a moisturizer
What type of foundation do you use?*

PowderCreamLiquidNone - I do not use a foundation
What type of nail/hand care do you use?*

Nail color / polishHand creamCuticle cream / oilNone - I do not use nail / hand care
When shopping for skincare, what solutions do you typically look for?*

AcneBack acneAcne scarringAcne pittingBlackheadsOilinessPoresUnder eye bagsPuffinessHyperpigmentationSkin allergiesDietary restrictionsWrinkles / fine linesCrow's feetSagging skinDry / flaking skinDehydrationUneven skin textureUneven skin tone
What type of specialty products do you use?*

Eye treatment (cream, lotion, etc.)Alpha Hydroxy Acids (lactic acid, glycolic acid, etc.)Acne / pimple products (benzoyl peroxide, salycylic acid, etc.)Other
Have you ever used Ivory soap?*
If yes, do you experience the feeling of any of the following when using?*

DrynessRoughnessItchingRednessBurningNone of the above
Media Lab Science!
What medium(s) are you interested in?*

PhotoVideo reviewProduct testingContent creation

Thank you for completing the form!

We will contact you if we need further information or if you are eligible for a study.
This form has been completed ot the best of my knowledge, and I consider myself to be in good general health.*

Yes
This collected information will be used by ALS to determine my eligibility in clinical studies. This information is kept confidential and will not be disclosed to anyone outside of ALS. For California residents, you can read more to understand the privacy considerations taken according to the California Consumer Privacy Act (CCPA).
I understand and agree to ALS using this information to determine my eligibility in clinical studies. I also understand the limitations and use of my private information*

Yes
Please take a moment to read and understand the ALS Privacy Policy.
I have read, understand, and agree to the contents within the ALS Privacy Policy.*

Yes
I understand that this collected information will be used by ALS to determine my eligibility in clinical studies. This information is kept confidential and will not be disclosed to anyone outside of ALS. For California residents, additional information pertaining to the California Consumer Privacy Act (CCPA) can be found at https://oag.ca.gov/privacy/ccpa.*

Yes
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Participate in Our Studies!

Tell us about yourself!

Tell us about your health!

Tell us about your lifestyle!

Tell us about your skincare!

Media Lab Science!

Thank you for completing the form!