IBS Study

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Full Name* This field is required.
First Name
Last Name
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What is your age?
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Hidden - Age Value
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Hidden - Age Pass/Fail
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Are you pregnant, planning a pregnancy, or breastfeeding?* This field is required.
Yes
No
N/A - Male volunteer
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Hidden - Are you pregnant, planning a pregnancy or breastfeeding?* This field is required.
Yes
No
N/A - Male volunteer
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Have you experienced pain or discomfort related to your IBS at least once per week over the last 3 months?* This field is required.
Yes
No
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Hidden - Have you experienced pain or discomfort related to your IBS at least once per week over the last 3 months?* This field is required.
Yes
No
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Have you been diagnosed with any (other) medical conditions?* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
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Hidden - Have you been diagnosed with any (other) medical conditions* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
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Please specify what medical conditions you have been diagnosed with* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc.
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Have you had any C. difficile infections in the last 2 years?* This field is required.
Yes
No
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Hidden - Have you had any C. difficile infections in the last 2 years?* This field is required.
Yes
No
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Do you have any history of pancreatitis?* This field is required.
Yes
No
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Hidden - Do you have any history of pancreatitis?* This field is required.
Yes
No
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Have you been diagnosed with any substance abuse or attended rehab in the last 2 years?* This field is required.
Yes
No
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Hidden - Have you been diagnosed with any substance abuse or attended rehab in the last 2 years?* This field is required.
Yes
No
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Have you required hospitalization due to a psychiatric disorder in the last 3 years or have you any history of attempted suicide?* This field is required.Hospitalization refers to staying overnight in a facility for treatment or observation
Yes
No
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Hidden - Have you required hospitalization due to a psychiatric disorder in the last 3 years or have you any history of attempted suicide?* This field is required.
Yes
No
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Are you currently taking any medications or supplements?* This field is required.i.e. any medication or supplement including daily multivitamin, minerals, probiotics
Yes
No
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Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
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Please specify what medications or supplements you are currently taking* This field is required.If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure
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Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.i.e. food allergies
Yes
No
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Hidden - Have you been diagnosed with any allergies or intolerances by a physician or healthcare professional?* This field is required.
Yes
No
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Please specify which allergies or intolerances you have* This field is required.Please state if it is an intolerance or allergy
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Phone Number* This field is required.
087/021
1234567
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Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
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Would you like to be subscribed to Atlantia's database?* This field is required.Subscribing to this allows us to contact you occasionally via email with study updates or new studies
Yes, Subscribe Me
No, thank you.
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Consent to mailing list - hidden* This field is required.
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Where did you hear about the study?* This field is required.
Instagram
Facebook
Previous Participant
Email
Friend/Family Member
Google Search
Website Ad
Flyer
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Consent to Privacy Notice* This field is required.We need your explicit consent to process the personal data collected as part of this form in particular, health data. All personal data relevant to pre-screening for trials is processed in accordance with our Privacy Notice. You can withdraw consent by contacting us at dataprotectionofficer@atlantiatrials.com Do you consent to Atlantia Food Clinical Trials Ltd. processing the information you have provided in this form for the purpose of assessing your eligibility for this trial
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Score* This field is required.
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Reason* This field is required.
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Form Status* This field is required.
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