COGI Membership

  • Color of Gastrointestinal Illnesses Membership Form

  • Are you the patient, parent, or care partner?*
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  • Care Connection Member Survey

    This section allows COCCI to record, evaluate, and understand the experiences of patients and caregivers battling digestive diseases in communities of color.
  • Do you have health insurance?*
  • What is your preferred learning style for education? Select all that apply.*
  • Do you have difficulties reading or writing?*
  • What is your disability status?*
  • Do you have a diagnosis? If yes, select all that apply.*
  • If yes or other, do you have a clear understanding of your diagnosis?
  • Are you interested in a second opinion?
  • Will you travel for a second opinion?
  • Are your symptoms properly managed?
  • Do you have a clear understanding of your medications?
  • What medications are you currently taking for Inflammatory Bowel Disease?
  • Do you, or the person you take care of, have an ostomy?
  • What medications are you currently taking for Inflammatory Bowel Disease?
  • Are you interested in participating in clinical research?*
  • Do you want additional information on clinical research?*
  • Do you have family support?*
  • How is your mental health?*
  • Do you need mental health support?*
  • What are your previous/current mental health conditions?*
  • Is your mental health affecting your care/condition?*
  • Do you want/need appeals assistance?

  • Should be Empty: