IBS Clinical Research Questionnaire
Thank you for your interest in our clinical trial to study the effect of a new investigational drug on IBS and its symptoms. Answer the questions below to see if you are eligible.
Have you been diagnosed with any of the following types of IBS by a doctor?
IBS-C - constipation predominant
IBS-D - diarrhea predominant
IBS-M - IBS with both constipation and diarrhea
No
Have you experienced recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with at least two of the following criteria:
Related to defecation.
Associated with a change in frequency of stool.
Associated with a change in form (appearance) of stool.
No, None of these
Not Sure
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If you are taking Tricyclic antidepressants / SSRIs or Benzodiazepines (such as Valium and Xanax)? Have you followed the prescribed dosing for at least 90 days, and be willing to continue the regimen throughout the study period?
Yes
I am taking one or more of these medications, but I want to change
I am not taking any of these medications
I’m not sure
Have you taken any of the following, for any reason, in the last 30 days?
Opioid based painkillers
Medical or recreational marijuana or THC
CBD or any other cannabidiol derivatives
No
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Full Name
*
First Name
Last Name
Facebook Submission ID
Preferred Method of Contact
Email
Phone
Email
example@example.com
Phone Number
Phone Number (old)
Address
Street Address
Street Address Line 2
City
Please Select
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Alaska
Arizona
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California
Colorado
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Delaware
District of Columbia
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Birthday (Must be 18 - 70 to qualify.)
/
Month
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Day
Year
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If you qualify and participate in a study, you may receive:
Investigational medication for IBS, or placebo
No-cost study-related care
Compensation for time and travel
All answers will be kept confidential.
Preferred Trial Location
Select Location
Aurora, CO
Beachwood, OH
Cleveland, OH
Gastonia, NC
Meridian, ID
Raleigh, NC
Salem, OR
Tampa, FL
Site ID
Pass
Is it ok for us to share your responses and your contact details with members of the selected trial location above and contact you directly about the information you've provided?
Yes
No
Submit
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