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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.

Participant Pre-flight Questionnaire_submit_Page_1
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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.

 

 

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?

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

4. Do you suffer from high blood pressure?

5. Do you suffer from low blood pressure?

6. Do you have high cholesterol?

7. Are you currently receiving medical care?

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

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

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

11. Do you have a history of alcohol abuse?

12. Do you currently drink?

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

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

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

16. Do you currently use or take medication?

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.)

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

3. Asthma or wheezing with breathing or exercise?

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

5. Pneumothorax (collapsed lung)?

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

7. A heart attack?

8. Dizziness, blackouts or fainting?

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

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

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

12. Frequent colds, sinusitis or bronchitis?

13. Stroke or any heart or stroke disorders?

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

15. Heart or blood vessel surgery?

16. Sinus surgery?

17. Diabetes?

18. Kidney stones?

19. Recurrent back or neck problems?

20. Back or spinal surgery?

21. Osteoporosis?

22. A suicide attempt?

23. Radiation treatment or exposure?

24. Frequent or severe headaches?

25. Any nose, throat or speech disorder?

26. Motion sickness requiring medication?

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

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

29. Anemia or sickle cell trait?

30. A positive HIV test?

31. A positive tuberculosis skin test or active tuberculosis?

32. Any blood disorders?

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

34. Cancer of any type?

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

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

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?

2. High blood pressure?

3. Epilepsy?

4. Diabetes?

5. Glaucoma?

6. High cholesterol?

7. Osteoporosis?

8. Mental illness?

9. Allergies or asthma?

10. Any inherited disorders?

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?

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

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

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

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

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)

(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.)

(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.