Name *

First Name

Last Name

Phone *

(###)

###

####

Do you smoke? *

Yes

No

Gender *

Male

Female

Other - not - prefer - not - to - say

Are you interested in participating in a clinical trial?* *

* Note: if you are selected: (1) you will have an opportunity to purchase an FDA-approved cholesterol medicine without a prescription for 6 months, (2) you will need to meet virtually with a clinician at the beginning and end of the 6-month period.

Yes

No

My Blood Pressure is: *

Normal (120/80)

Elevated (130/85)

High (145/95)]

I have Diabetes: *

Yes

No

I identify my ethnicity as: *

(select all that apply)

Asian

Black/African

Caucasian

Hispanic/Latino

Native American

Pacific Islander