Pre-Participant Questionnaire

Seeking Volunteers!
The University of Texas Medical Branch (UTMB), in conjunction with the National Aerospace Training and Research (NASTAR) Center in Southampton, PA http://www.nastarcenter.com, is conducting
research into the safety of spaceflight passengers with medical conditions.

Volunteers are invited to participate in the experiment and experience a simulated spaceflight. The simulated space flight environment will be produced using a high- performance centrifuge-based simulator called the ATFS-400. This simulator is capable of generating high onset-offset, sustained acceleration (“G”) forces similar to those that might be experienced in high performance aircraft or spacecraft. More information on the AFTS-400 can be found at https://www.etcaircrewtraining.com/.
When you arrive at the NASTAR Center you will be trained on various aspects of spaceflight and then evaluated (via questionnaires, psychological sensors, and basic cognitive tasks) during a full-scale version of the acceleration profile. The maximum G-level you may experience is +4Gz (acceleration aligned with your body-longitudinal axis, or head-to-toe, up to 4 times the force of gravity) and +8Gx (acceleration aligned in the thrust-forward direction, or chest-to-back, up to 6 times the force of gravity). We will train you on certain techniques that are commonly used to mitigate the physiological effects of G-forces. You may terminate your participation at any time without reason or repercussion. There is no compensation for time, travel, lodging, or other expenses associated with your participation in this experiment.

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Benefits
•     The knowledge obtained from this research study may serve to improve future suborbital spaceflight training and
       simulation protocols and may help improve spaceflight passenger inclusion/exclusion selection criteria.
•     You will get to experience a hypergravity simulated space launch produced by the high performance AFTS- 400
       simulator.

Requirements
•     Must be 18 years old or older, and a U.S citizen or Green Card holder.
•     Must be of adequate health as determined by applicable NASTAR Center criteria.
•     Must be able to commit to one full day of training (7:30am – 5:30pm). It is recommended that airline travel NOT be
       pursued on the same day of training.

Seeking
•     Volunteers with diagnosed diabetes mellitus and/or cardiac arrhythmias
•     Volunteers without history of these medical conditions If you or anyone that you know is interested in volunteering
       to be a research participant, please register using the pre-participation questionnaire above.

For more information please email rsblue@utmb.edu.

Instructions:

The purpose of this Medical Questionnaire is to gather information regarding your current and past medical status. For each positive response to a question, please provide additional details in the remarks section below. If you are unsure of the answer to any of the following questions, please consult with your personal physician.

Full Name:

Date of Birth:

Address:

Phone Number:

Height (inches):

Mobile Number:

Gender

Weight (pounds):

GENERAL:
(Please check yes or no, as applicable, and give details in the remarks section below for any positive response.)

1. Do you currently Smoke?

Yes

2. Are you or have ever been a heavy smoker (1 pack + per day)?

Yes

3. If you were a smoker but you no longer smoke, how long ago did you stop?

4. Do you suffer from high blood pressure?

Yes

5. Do you suffer from low blood pressure?

Yes

6. Do you have high cholesterol?

Yes

7. Are you currently receiving medical care?

Yes

8. Have you had any recent admissions to hospital (within the last 5 years)?

Yes

9. Have you had any significant illness or injury in the last 5 years?

Yes

10. Have you been substance dependent, failed a drug test or used illegal substances in the last 5 years?

Yes

11. Do you have a history of alcohol abuse?

Yes

12. Do you currently drink?

Yes

13. Are you a heavy drinker (7+ units a day)?

Yes

14. Have you ever experienced decompression sickness (the bends)?

Yes

15. Have you ever had an application for health or life insurance rejected?

Yes

16. Do you currently use or take medication?

Yes

MEDICATIONS:

Please list all medications, including dosage and frequency, which you are currently using or taking. List "None" if not taking.

Do you have or have you ever had (or received treatment for) any of the following:(Please tick yes or no, as applicable, and give details in the remarks section below for any positive response.)

1. Allergies or hay fever? (Include allergies to any medications.)

Yes

2. An inability to perform moderate exercise (e.g. walk 1.6km/1 mile in 12 minutes)?

Yes

3. Asthma or wheezing with breathing or exercise?

Yes

4. Any form of lung or chest disease or surgery?

Yes

5. Pneumothorax (collapsed lung)?

Yes

6. Heart disease (e.g. angina, murmur, pacemaker)?

Yes

7. A heart attack?

Yes

8. Dizziness, blackouts or fainting?

Yes

9. A head injury, concussion or loss of consciousness for any reason?

Yes

10. Any neurological disorders, epilepsy, a seizure or paralysis?

Yes

11. Eye trouble or an eye operation (except for wearing glasses or contact lenses)?

Yes

12. Frequent colds, sinusitis or bronchitis?

Yes

13. Stroke or any heart or stroke disorders?

Yes

14. Ear disease or surgery or any hearing loss or balance disorders?

Yes

15. Heart or blood vessel surgery?

Yes

16. Sinus surgery?

Yes

17. Diabetes?

Yes

18. Kidney stones?

Yes

19. Recurrent back or neck problems?

Yes

20. Back or spinal surgery?

Yes

21. Osteoporosis?

Yes

22. A suicide attempt?

Yes

23. Radiation treatment or exposure?

Yes

24. Frequent or severe headaches?

Yes

25. Any nose, throat or speech disorder?

Yes

26. Motion sickness requiring medication?

Yes

27. An allergic reaction to any anti-motion sickness medications?

Yes

28. Stomach, liver or intestinal trouble (e.g. reflux, ulcers, colostomy, ileostomy, hernia, gallstones, gallbladder disease, etc.)?

Yes

Third Choice

29. Anemia or sickle cell trait?

Yes

30. A positive HIV test?

Yes

31. A positive tuberculosis skin test or active tuberculosis?

Yes

Third Choice

32. Any blood disorders?

Yes

33. Weakened limbs or joints or any broken bones within the past year?

Yes

34. Cancer of any type?

Yes

35. Psychological or psychiatric disorders of any sort (e.g. claustrophobia, depression, anxiety, etc.)?

Yes

36. A disability or functional impairment that may require accommodation?

Yes

FAMILY HISTORY:
Do you have a FAMILY HISTORY of any of the following:

(Please tick yes or no, as applicable, and give additional details in the remarks section below for any positive response.)

1. Heart disease?

Yes

2. High blood pressure?

Yes

3. Epilepsy?

Yes

4. Diabetes?

Yes

5. Glaucoma?

Yes

6. High cholesterol?

Yes

7. Osteoporosis?

Yes

8. Mental illness?

Yes

9. Allergies or asthma?

Yes

10. Any inherited disorders?

Yes

Females only:
(Please tick yes or no, as applicable, and give additional details in the remarks section below for any positive response.)

1. Have you ever had or do you currently have any gynecological conditions?

Yes

2. Have you ever had or do you currently have any menstrual problems?

Yes

3. Have you ever had or do you currently have any obstetric complications?

Yes

4. Are you currently pregnant or are you trying to become pregnant?

Yes

5. Have you had a pregnancy that has ended within the past 6 weeks?

Yes

EXERCISE:
During a typical 7-day period, how many times and for how long on average do you exercise for more than 15 minutes at a level that increases your heart rate? Please enter the times per week and duration for each level of exercise that you perform.

1. Strenuous Exercise (heart beats rapidly) Running, jogging, hockey, football, soccer, squash, basketball, cross country skiing, roller skating, swimming, vigorous bicycling, etc.

Number of Times per Week?

For How Long?

2. Moderate Exercise (heart rate increased) Fast walking, baseball, tennis, easy bicycling, volleyball, easy swimming, alpine skiing, golf (walking the course), etc.

Number of Times per Week?

For How Long?

3. Mild Exercise (minimal effort) Yoga, fishing, bowling, golf (riding a cart), easy walking, etc.

Number of Times per Week?

For How Long?

4. Please estimate how many flights of stairs you can climb at a rapid pace without stopping to catch your breath. (Less than 3, 3 to 5, more than 5)

Number of Times per Week?

For How Long?

ADVENTURE EXPERIENCE AND LIFESTYLE:

(Please provide additional information describing any adventure travel experiences in which you have participated and lifestyle experiences such as being a pilot, SCUBA diver, skydiver, etc.)

REMARKS:

(Please provide additional information here for ALL positive responses to ANY of the questions in this Medical Questionnaire.)

Supporting Documents:

Please upload supporting documents here.

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Pre-Participant Questionnaire

GENERAL: (Please check yes or no, as applicable, and give details in the remarks section below for any positive response.)

Do you have or have you ever had (or received treatment for) any of the following:(Please tick yes or no, as applicable, and give details in the remarks section below for any positive response.)

FAMILY HISTORY:Do you have a FAMILY HISTORY of any of the following:

(Please tick yes or no, as applicable, and give additional details in the remarks section below for any positive response.)

Females only:(Please tick yes or no, as applicable, and give additional details in the remarks section below for any positive response.)

EXERCISE:During a typical 7-day period, how many times and for how long on average do you exercise for more than 15 minutes at a level that increases your heart rate? Please enter the times per week and duration for each level of exercise that you perform.

1. Strenuous Exercise (heart beats rapidly) Running, jogging, hockey, football, soccer, squash, basketball, cross country skiing, roller skating, swimming, vigorous bicycling, etc.

2. Moderate Exercise (heart rate increased) Fast walking, baseball, tennis, easy bicycling, volleyball, easy swimming, alpine skiing, golf (walking the course), etc.

3. Mild Exercise (minimal effort) Yoga, fishing, bowling, golf (riding a cart), easy walking, etc.

4. Please estimate how many flights of stairs you can climb at a rapid pace without stopping to catch your breath. (Less than 3, 3 to 5, more than 5)

GENERAL:
(Please check yes or no, as applicable, and give details in the remarks section below for any positive response.)

FAMILY HISTORY:
Do you have a FAMILY HISTORY of any of the following:

Females only:
(Please tick yes or no, as applicable, and give additional details in the remarks section below for any positive response.)

EXERCISE:
During a typical 7-day period, how many times and for how long on average do you exercise for more than 15 minutes at a level that increases your heart rate? Please enter the times per week and duration for each level of exercise that you perform.