Join | ContactME-IBS

UK Resident*

I live in the UK

This study database is only available to residents of the UK

By completing this form you give permission for your information to be stored securely and for as long as necessary on the ContactME-IBS Research register.

You understand that you may be contacted about potential relevant research in the future.

You understand that anonymised information from the register will be used to assess the register's impact on research participation.

Have you ever been diagnosed as having IBS?*

Yes
No

By whom were you diagnosed?*

GP
Specialist

Do you recognise these symptoms?

Please tick ALL that apply
(Please note that you must be able to tick 2 or more to be eligible for this register)

Do you recognise any of these symptoms?

Do you have recurring abdominal pain (at least 1 day per week) which has been present for at least 6 months?
Do you suffer from constipation (difficulty emptying your bowels) which has been present for at least 6 months?
Do you suffer from intermittent episodes of diarrhoea which has been going on for at least 6 months?
If you have abdominal pain is this related to moving your bowels (how often you go, or appearance of stool)?

Thank you for answering these preliminary questions. You are eligible to register to our IBS Database.
Please fill in your contact details below and we will be in touch when a study becomes available where you can participate.

NumberTickedSymptoms

Address*

Street Address Address Line 2 Town/City County Postcode

Name*

First Last

Email

Gender*

Date of Birth*

Telephone

Where did you receive the leaflet?*

How did you hear about this study?*

Where did you see the poster?*

In which GP Practice?*

In which pharmacy?*

In which Public Place?*

At which Event?*

In which Hospital?*

Please state the name of the Hospital / GP site you saw the register on*

Are you happy for your GP to be informed of your participation?*

Yes
No

Please state the name of the Hospital / GP site you saw the register on*

Which social media site did you see the study on?*

Please state where you heard about this register (including GP Surgery name or name of Hospital)*

Whose Twitter feed was this seen on?*

Whose Facebook feed was this seen on?*

Please state the name of the feed you saw this on*

ContactME-IBS Registration Form

ContactME-IBS Registration Form

Do you recognise these symptoms?