Active UC Study
This questionnaire is for patients presenting with active Ulcerative Colitis (UC) flares, the following questions are designed to gather essential information regarding their condition, treatment history, and willingness to participate in clinical trials. This questionnaire can help facilitate recruitment for studies focused on patients experiencing active UC flares.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Doctor Name
First Name
Last Name
Doctor Practice Name
Doctor Phone Number
Please enter a valid phone number.
What is your age?
*
Sex
*
What is your ethnicity? (Select all that apply)
Caucasian
African American
Hispanic or Latino
Asian
Other
When were you diagnosed with Ulcerative Colitis?
*
Less than 1 year ago
1-5 years ago
More than 5 years ago
How would you rate the severity of your current symptoms ona scale of 1 to 10? (1 being mild and 10 being severe)
*
Have you participated in any clinical trials for Ulcerative Colitis in the past?
*
Yes
No
Do you have a support system (family, friends, healthcareproviders) to assist you during a clinical trial?
*
Yes
No
By submitting your personal identifying information through this form, you acknowledge and agree to the following: The information you provide will be used solely for the purpose of qualifying you for a clinical trial and your information will be handled in accordance with our Privacy Policy. You are not required to submit any information, but doing so may be necessary to receive certain services or information. We will not sell, trade, or rent your personal information to third parties.
*
Submit
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