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
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1
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31
Select
1900
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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
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