Pre-Screening Questions
How did you hear about us?
Google
Instagram
Facebook
Friend/Relative
Doctor
Other
What is your date of birth?
Month
Day
Year
Select
January
February
March
April
May
June
July
August
September
October
November
December
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Please select your gender:
Male
Female
Have you been diagnosed with IBS by a doctor?
Yes, IBS-C
Yes, IBS-D
Yes, IBS-Mixed Type
Yes, but I’m not sure which type
No
Do you experience abdominal pain?
Yes
No
Are you currently using, or have you used, opioids such as heroin, fentanyl, oxycodone, hydrocodone, codeine, and morphine, or cannabinoids such as medical or recreational marijuana, THC, CBD, or synthetic cannabinoids?
Yes
No
Are you currently taking any of the following medications?
Probiotics
Bulk laxatives such as: Benefiber, Metamucil, FiberCon, or Citrucel
Fiber
Stool softeners such as: Colace, Ex-Lax Stool Softener, or Surfak
Pepto-Bismol
Yes
No
Are you currently taking any medications for your IBS that are NOT listed below?
Probiotics
Bulk laxatives such as: Benefiber, Metamucil, FiberCon, or Citrucel
Fiber
Stool softeners such as: Colace, Ex-Lax Stool Softener, or Surfak
Pepto-Bismol
Yes
No
I'm not sure
Have you had any colonic or major abdominal surgery? Examples include bariatric surgery (including gastric banding), having your gallbladder removed, stomach surgery, small/large bowel surgery or abdominal large vessel surgery.
Yes
No
I'm not sure
Do you have a history of colorectal cancer, inflammatory bowel disease, diverticulitis, ischemic colitis, microscopic colitis, bile acid diarrhea, or celiac disease?
Yes
No
I'm not sure
Do you have a history of any of the following diseases or problems?
Peptic ulceration
Functional dyspepsia
Gastrointestinal (GI) bleeding
Gastrointestinal (GI) inflammatory disease such as esophagitis, gastritis, or duodenitis
Yes
No
I'm not sure
Do you have Type 1 or Type 2 Diabetes?
Yes
No
I'm not sure
This study requires you to record some of your IBS symptoms in an eDiary (an electronic diary that captures data) every day throughout the study. Would you be willing to record your symptoms daily in order to participate in this study?
Yes
No
Unsure/Need more information
This study requires one overnight observation period at the study center to observe your response after the first day of taking the investigational treatment. Would you be willing to stay overnight at a study center in order to participate in this study?
Yes
No
I’m not sure/I need more information
If you choose to save your information, and we want to contact you in the future about the CAPTIVATE study, what is your preferred method of being contacted? Please note, your preference will be taken into consideration, but we may contact you using any methods you provide (SMS, Phone, Email).
Phone Call
Text Message
Email
Any of the above