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 Name
Last Name
Email
*
exemple@exemple.com
What is your age?
*
At what age have you been diagnosed with Ulcerative Colitis?
*
Did you have any coexisting conditions at the time you were diagnosed with Ulcerative Colitis?
*
Yes
No
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?
*
Yes
No
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 fill the board bellow with the current medication you are using to treat your Ulcerative Colitis
*
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)
Prior medication for Ulcerative Colitis
Please fill the board bellow with prior medications you have been using to treat your Ulcerative Colitis
*
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?
Yes
No
Please fill the board bellow
*
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)
Please consent to the following
*
I am 18 years old or older and I am legally entitled to give consent for the collection and retention of this information by UC Well.
This information is being collected to support the study of ulcerative colitis and that the information extracted from this form will be used without my name (if provided) or email address.
I am not receiving financial benefit for submitting this information and do so at my own free will.
This form will be retained securely and in confidence by UC Well for no longer than necessary.
Personal data provided in this form will be used and retained in accordance with UC Well Privacy Policy available on https://www.uc-well.com/privacy-policy
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