PROJECT TITLE: Consumption of barley-containing foods to lower risk of heart disease

SENIOR INVESTIGATORS: Kay M Behall, PhD, Judith Hallfrisch, PhD
Diet & Human Performance Lab, BHNRC, USDA
Building 308, BARC-East, Beltsville, MD 20705
Fx 301-504-9098, email behall@bhnrc.arsusda.gov or hallfrij@ba.ars.usda.gov

Name_____________________Height_______Weight______Birthdate___________
Work Address____________________________________Phone_______________

Home Address____________________________________Phone______________

If you have previously participated in a diet study, please give date(s) and type of study________________________________________________________________

___________________________________________________________________

Have you been in good health for the past 3 years?______if not, please explain ___________________________________________________________________

Has your weight changed more than 15 pounds in the last year?____How much?_____

Are you now using nonprescription drugs or vitamins?_______If yes, please list by name and amount____________________________________________________

Would you be willing do discontinue these for the study?_______________________

Are you now using medicine prescribed by a physician?______If yes, list drugs by name and amount _____________________________________________________

Are you willing to have blood drawn and collect urine during the study?___________

Are you now eating a special diet?______Are you allergic, unable, or unwilling to eat any specific foods? ________Please list if yes.______________________________

Would you rate your physical activity level as: very active____normal____low_____

Have you been treated for heart disease_______diabetes_______
high blood pressure________

Does your familiy have a history of heart disease_____diabetes___?

Do you smoke_____How many cigarettes/day?______pipe_____cigars_____