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Severe Constipation Study Questionnaire
Please fill out all required questions - this will help us determine your eligibility for the study. The questionnaire will take approx. 2 mins to complete
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HIPAA
Compliance
1
Full Name
*
This field is required.
First Name
Last Name
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2
Are you aged between 18-75?
*
This field is required.
This is inclusive of 18 & 75
Yes
No
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3
Hidden - Are you aged between 18-75?
Yes
No
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4
Are you pregnant, breastfeeding or planning a pregnancy?
*
This field is required.
Yes
No
N/A - Male
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5
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
Yes
No
N/A - Male
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6
How many bowel movements do you have, on average, per week?
*
This field is required.
Less than 1 per week
1 per week
2 per week
3 per week
4 per week
5 per week
6 or more per week
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7
Hidden - How many bowel movements do you have per week?
*
This field is required.
Less than 1 per week
1 per week
2 per week
3 per week
4 per week
5 per week
6 or more per week
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8
Have you been diagnosed with any medical conditions?
*
This field is required.
e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
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9
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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10
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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11
Are you currently taking any medications or supplements?
*
This field is required.
e.g blood pressure/cholesterol meds, multivitamins, probiotics or prebiotics
Yes
No
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12
Hidden - Are you currently taking any medications or supplements?
*
This field is required.
Yes
No
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13
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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14
Have you been diagnosed with any allergies or intolerances by a doctor or healthcare professional?
*
This field is required.
i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose
Yes
No
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15
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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16
Please specify which allergies or intolerances you have
*
This field is required.
i.e. seasonal, medication, or food allergies, or intolerances to gluten, lactose
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17
Have you previously had any gastrointestinal surgery?
*
This field is required.
Yes
No
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18
Hidden - Have you previously had any gastrointestinal surgery?
*
This field is required.
Yes
No
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19
Please specify the type of surgery you had performed
*
This field is required.
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20
Phone Number
*
This field is required.
087/021
1234567
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21
Email
*
This field is required.
For contact regarding this study
example@example.com
Confirm Email
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22
Would you like to be subscribed to Atlantia's database?
*
This field is required.
Yes, Subscribe Me
No, thank you.
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23
Consent to mailing list - hidden
*
This field is required.
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24
Where did you hear about the study?
*
This field is required.
Instagram
Facebook
Previous Participant
Email
Yaycork
Family/Friend
Google Search
Website Ad
Flyer
UCC
MTU
Red FM
Cork Independent
96FM/C103
Classic Hits
Other
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25
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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26
Score
*
This field is required.
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27
Reason
*
This field is required.
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28
Form Status
*
This field is required.
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