Constipation Study

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Full Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
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Today's Date
Date
Month
Day
Year
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Hidden - Days Calculation
5
Hidden - Age Calculation
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Hidden - Age Form Value
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Hidden - Age Pass/Fail
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Are you pregnant, breastfeeding or planning a pregnancy?* This field is required.
Yes
No
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Hidden - Are you pregnant, breastfeeding or planning a pregnancy?* This field is required.
Yes
No
10
How many bowel movements, on average, 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 or more per week
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Hidden - How many bowel movements, on average, do you have per week?
Less than 1 per week
1 per week
2 per week
3 per week
4 per week
5 or more per week
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Have you been diagnosed with any medical condition?* This field is required.e.g. High blood pressure, high cholesterol, celiac disease, etc
Yes
No
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Hidden - 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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Please specify what medical condition(s) you have* This field is required.
15
Are you currently taking any medications or supplements?* This field is required.i.e. any medication or supplement e.g. daily blood pressure meds, diabetes, cholesterol, multivitamin, etc
Yes
No
16
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 previously had any gastrointestinal surgery?* This field is required.
Yes
No
19
Hidden - Have you previously had any gastrointestinal surgery?
Yes
No
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Please specify the type of surgery you had* This field is required.
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Do you suffer from any allergies/intolerances?* This field is required.
Yes
No
22
Hidden - Do you suffer from any allergies/intolerances?
Yes
No
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Please specify what allergies/intolerances you havePlease specify in your answer if when referring to an allergy or intolerance
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Phone Number* This field is required.
Please enter a valid phone number.
25
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.
27
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
DO312
ChicagoTwentySomething
Family/Friend
Website Ad
Email
Google Search
Flyer
Other
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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.
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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.
Should be Empty: