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Constipation Study Questionnaire
Please fill out all required questions - this will help us determine your eligibility for the study. The questionnaire will take approx. 4 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
Date of Birth
*
This field is required.
-
Date
Month
Day
Year
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3
Today's Date
-
Date
Month
Day
Year
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4
Hidden - Days Calculation
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5
Hidden - Age Calculation
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6
Hidden - Age Form Value
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7
Hidden - Age Pass/Fail
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8
Are you pregnant, breastfeeding or planning a pregnancy?
*
This field is required.
Yes
No
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9
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
*
This field is required.
Yes
No
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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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11
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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12
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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13
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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14
Please specify what medical condition(s) you have
*
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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
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16
Hidden - Are you currently taking any medications or supplements?
*
This field is required.
Yes
No
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17
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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18
Have you previously had any gastrointestinal surgery?
*
This field is required.
Yes
No
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19
Hidden - Have you previously had any gastrointestinal surgery?
Yes
No
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20
Please specify the type of surgery you had
*
This field is required.
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21
Do you suffer from any allergies/intolerances?
*
This field is required.
Yes
No
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22
Hidden - Do you suffer from any allergies/intolerances?
Yes
No
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23
Please specify what allergies/intolerances you have
Please specify in your answer if when referring to an allergy or intolerance
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24
Phone Number
*
This field is required.
Please enter a valid phone number.
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25
Email
*
This field is required.
For contact regarding this study
example@example.com
Confirm Email
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26
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.
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27
Consent to mailing list - hidden
*
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28
Where did you hear about the study?
*
This field is required.
Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
Other
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29
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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30
Score
*
This field is required.
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31
Reason
*
This field is required.
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32
Form Status
*
This field is required.
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