UC Medical History Study

UC Medical History Study

*Please note that it is advised to complete this form on a desktop computer. UC well is collecting information about patients diagnosed with Ulcerative Colitis and their medical history with the disease.
Name

First NameLast Name
Email
exemple@exemple.com
What is your age?
Where do you live (optional)

Numéro et rue

Complément d'adresse

VilleState

Code PostalCountry
At what age were you diagnosed with Ulcerative Colitis?
Did you have any coexisting medical conditions at the time you were diagnosed with Ulcerative Colitis?
Please describe the coexisting conditions by specifying the name and the diagnosis year for each condition
Did you have a past medical history of medical conditions prior to diagnosis of Ulcerative Colitis?
Please describe the past medical history of medical conditions by specifying the name and the diagnosis year for each condition
Current medication for Ulcerative Colitis

Please complete the table below with the current medication you are using to treat your Ulcerative Colitis.

Rows	Name	Dosage	Date started (month/year)	Response to Treatment (i.e., none, partial, complete remission)	Persistent Gastrointestinal Symptoms (i.e., rectal bleeding, rectal pain, abdominal pain, tenesmus, diarrhea)
First drug used
Second drug used (if any)
Third drug used (if any)
Fourth drug used (if any)
Fifth drug used (if any)

Please complete the table below with prior medications (if any) you have used to treat your Ulcerative Colitis. (optional)

Rows	Name	Dosage	Date started (month/year)	Response to Treatment (i.e., none, partial, complete remission)	Reason for discontinuing medication (if applicable)
First drug used
Second drug used (if any)
Third drug used (if any)
Fourth drug used (if any)
Fifth drug used (if any)

Treatment History of UC with R-dihydrolipoic acid (RDLA)
Have you used or are you currently using R-dihydrolipoic acid (RDLA) in the management/treatment of your Ulcerative Colitis?

Rows	Brand	Dosage	Date started (month/year)	Response to Treatment (i.e., none, partial, complete remission)	Reason for discontinuing medication (if applicable)
First source of RDLA
Second source of RDLA (if any)
Third source of RDLA (if any)

Current medication for Ulcerative Colitis