Dairy Intolerance Study

1
Name* This field is required.
First Name
Last Name
2
Sex* This field is required.
Male
Female
3
Phone Number* This field is required.
Area Code
Phone Number
4
Email* This field is required.
example@example.com
5
Preferred Method of Contact* This field is required.
Call
Text
Email
6
Zipcode* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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Namibia
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New Caledonia
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Nigeria
Niue
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Norway
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Paraguay
Peru
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Poland
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Other
Country
7
Date of Birth* This field is required.
Date
Month
Day
Year
8
Which of the following best describes you and dairy products (select one)* This field is required.
I have been clinically diagnosed as Lactose Intolerant
I have never been clinically diagnosed, but I strictly avoid consuming dairy products
I have never been clinically diagnosed, but consuming dairy products upsets my stomach
I have never been clinically diagnosed, I do NOT avoid consuming dairy products, and consuming dairy products does NOT upset my stomach.
9
Are you pregnant, suspect you may be pregnant, or have you recently been pregnant and are currently nursing?* This field is required.
YESNO
10
Are you diabetic?* This field is required.
YESNO
11
Do you currently use nicotine products, or have you stopped using nicotine products within the last 12 months?* This field is required.
YESNO
12
Do you live or work within an environment that chronically exposes you to second-hand smoke?* This field is required.
YESNO
13
Do you currently use recreational drugs or medicinal marijuana, or have you stopped using recreational drugs or medical marijuana within the last 12 months?* This field is required.
YESNO
14
Have you been clinically diagnosed with and/or are you receiving treatment for Inflammatory Bowel Syndrome (IBS), Crohn's Disease, Colorectal Cancer, or Colitis?* This field is required.
YESNO
15
Have you ever undergone gastric bypass surgery, or have you undergone an abdominal or other gastrointestinal surgery within the last 12 months?* This field is required.
YESNO
16
Have you undergone a colonoscopy within the last 2 weeks?* This field is required.
YESNO
17
Are you taking, or have you taken probiotics within the last 2 weeks?* This field is required.
YESNO
18
Qualified for study?* This field is required.
YESNO
19
Congratulations! You have pre-qualified for our dairy intolerance study! We will reach out to you as soon as possible via your chosen preferred method of contact.
20
Please verify that you are human* This field is required.
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Thank you for taking the time to support UMHB Research!! Unfortunately though, you do not qualify for the current study. If you would like for us to contact you for future studies, please click ‘YES, Contact Me For Future Studies’. Otherwise, click ‘NO, Please Delete My Contact Information.’
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Would you like to be notified of other future studies?* This field is required.
YES, Contact Me for Future StudiesNO, Please Delete my Contact Information
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