Prebiotic Study

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Full Name* This field is required.
First Name
Last Name
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What is your sex?* This field is required.
Female
Male
Other
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Hidden - What is your sex?* This field is required.
Female
Male
Other
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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
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Hidden - Age Calculation
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Hidden - Age Form Value
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Hidden - Age Pass/Fail
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Please enter your weight and height* This field is required.Note: You can toggle between imperial and metric using the arrow icon
11
Hidden - BMI Calculation
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Hidden - BMI Form Value
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Hidden - BMI Pass/Fail
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Are you pregnant, breastfeeding, or planning a pregnancy?* This field is required.
Yes
No
15
Hidden - Are you pregnant, breastfeeding, or planning a pregnancy?
Yes
No
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Do you have a purposefully high fiber diet?* This field is required.i.e. do you actively try to increase your fiber intake via food or supplements
Yes
No
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Hidden - Do you have a purposefully high fiber diet?
Yes
No
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Have you consumed any fermented foods in the past 28 days?e.g. Yogurt, kefir, kombucha
Yes
No
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Hidden - Have you consumed and fermented foods in the past 28 days?
Yes
No
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Have you been diagnosed with any medical condition(s)?* This field is required.e.g. High blood pressure, high cholesterol, depression, anxiety, celiac disease, HIV, 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 conditions you have been diagnosed with* This field is required.
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Are you currently taking any medications or supplements?* This field is required.e.g. daily blood pressure meds, diabetes, cholesterol, multivitamin, etc
Yes
No
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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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Phone Number* This field is required.
Please enter a valid phone number.
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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.
29
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
Email
Family/Friend
Google Search
Website Ad
Flyer
Chicago Moms Network
Natural Awakenings
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: