Infant Colic Study

1
Full Name* This field is required.
First Name
Last Name
2
Is your child aged between 3-12 weeks?* This field is required.
Not born yet
Younger than 3 weeks
Between 3-12 weeks
Older than 12 weeks
3
Hidden - Is your child aged between 3-12 weeks?
Not born yet
Younger than 3 weeks
Between 3-12 weeks
Older than 12 weeks
4
Was your child born at gestational age of 37 weeks or after?* This field is required.
At 36 weeks or before
At 37 weeks or after
5
Hidden - Was your child born at gestational age of 37 weeks or after?* This field is required.
At 36 weeks or before
At 37 weeks or after
6
Was your child born at a weight of 5.5lbs (2.5kg) or above?* This field is required.
Yes
No
7
Hidden - Was your child born at a weight of 5.5lbs (2.5kg) or above?* This field is required.
Yes
No
8
Were there any difficulties with the pregnancy/delivery* This field is required.
Yes
No
Unsure
9
Hidden - Were there any difficulties with the pregnancy/delivery* This field is required.
Yes
No
Unsure
10
Please specify what difficulties were experienced with the pregnancy/delivery* This field is required.
11
Has your child required hospitalization after initial discharge following delivery?* This field is required.Hospitalization here refers to being admitted into hospital overnight or longer in duration
Yes
No
12
Hidden - Has your child required hospitilization after initial discharge following delivery?* This field is required.
Yes
No
13
Does your infant cry for 3 or more hours a day, at least 3 days a week?* This field is required.
Yes
No
14
Hidden - Does your infant cry for 3 or more hours a day, at least 3 days a week?* This field is required.
Yes
No
15
Is the child's mother available to attend all 3 clinic visits?* This field is required.
Yes
No
16
Hidden - Is the child's mother available to attend all 3 clinic visits?* This field is required.
Yes
No
17
Have your child been diagnosed with any medical conditions?* This field is required.
Yes
No
18
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
19
Please specify what medical conditions they have been diagnosed with* This field is required.
20
Is your child currently taking any medications?* This field is required.
Yes
No
21
Hidden - Is your child currently taking any medications?* This field is required.
Yes
No
22
Please specify what medications they are currently taking* This field is required.
23
Is you child currently taking any supplements or probiotics?* This field is required.
Yes
No
24
Hidden - Is you child currently taking any supplements or probiotics?* This field is required.
Yes
No
25
Please specify what supplements or probiotics they are taking* This field is required.
26
Does your child suffer from any allergies/intolerances?* This field is required.
Yes
No
27
Hidden - Does your child suffer from any allergies/intolerances?* This field is required.
Yes
No
28
Please specify which allergies or intolerances they have* This field is required.
29
Phone Number* This field is required.
087/021
1234567
30
Email* This field is required.
example@example.com
Confirm Email
31
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.
32
Consent to mailing list - hidden* This field is required.
33
Where did you hear about the study?* This field is required.
Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
34
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.
35
Score* This field is required.
36
Reason* This field is required.
37
Form Status* This field is required.
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