Thank you for volunteering to register with UCLA Gastrointestinal (GI) Research Registry.
This registry has been designed to allow non-UCLA and UCLA Health System patients to voluntarily register themselves to be contacted for future research study participation relating to GI research. You will also be included in our quarterly research registry updates via email where you will be informed of future study participation opportunities that may be of interest to you. Below is a survey that will capture basic demographic information as well as future research study interests. Please answer the questions to the best of your ability. If you have any questions, please reach out to the Embedded Clinical Research and Innovation Unit at ResearchRegistry@mednet.ucla.edu or call us at 310-490-4888.
Before you begin, please read and save a copy for your records of the below research registry information sheet.
I have read the study information sheet and understand the purpose of the registry and I wish to consent to be part of the research registry survey.
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Yes
No
Thank you again for your interest!
Are you a UCLA patient?
* must provide value
Yes
No
Are you a UCLA student?
* must provide value
Yes
No
First Name
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Last Name
* must provide value
years old
You must be at least 18 years old to participate
Zip code
* must provide value
Phone Number
* must provide value
Email
* must provide value
Re-enter email
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Emails do not match.
Not matching
Please check that the emails you've entered match and are correct.
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Yes, emails are correct.
Gender
* must provide value
Male
Female
Non-binary
Prefer not to say
What is your ethnicity?
* must provide value
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
What is your racial background?
* must provide value
feet
inches
pounds
Do you have any of the following health conditions? Please select all that apply:
* must provide value
Alzheimer's Disease, dementia
Anemia or other blood disease
Asthma
Cancer
Chronic Kidney Disease
Chronic Lung Disease (Not Asthma BUT Emphysema, Pulmonary Fibrosis or Chronic Bronchitis, etc.)
Chronic Obstructive Pulmonary Disease
Diabetes
Digestive Problems (Abdominal pain, Diarrhea, Constipation, Ulcer, Colitis, Inflammatory Bowel Syndrome, or Gallbladder Disease)
Heart Disease (congestive heart failure, coronary artery disease)
High Blood Pressure (Hypertension)
High Cholesterol
Liver Disease
Mental Health/Mood Disorder
Memory Issues
Obesity
Parkinson's Disease
Rheumatological Disorder (Arthritis or Rheumatism)
Stroke
Thyroid Disease
Other
None
Please unselect all health conditions which you do not have before continuing to the next question.
Do you have any of the following GI health conditions? Please select all that apply:
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In the last 3 months, have you had abdominal pain?
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Yes
No
Is this abdominal pain only associated with your period?
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Yes
No
Not Applicable
In the last 3 months, how often did you have pain anywhere in your abdomen?
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Never
Fewer than 1 day a month
1 day a month
2-3 days a month
1 day a week
2-3 days a week
Most days
Every day
Multiple times per day
How often did this pain in your abdomen happen close in time to a bowel movement - just before, during, or soon after?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of times with pain
How often did your stools become either softer than usual or harder than usual when you had this pain?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of times with pain
How often did your stools become either more frequent than usual or less frequent than usual when you had this pain?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of times with pain
Has it been 6 months or longer since you started having this pain?
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Yes
No
In the last 3 months, when you had abnormal stools, what were they usual like? (Please answer this question based on your symptoms without taking medications affecting your stool, such as fiber, laxatives, anti-diarrhea medication, etc.)
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Usually constipation
Usually diarrhea
Both diarrhea and constipation - that is, more than ¼ of all the abnormal bowel movements were constipation and more than ¼ were diarrhea
Not applicable, because I never or rarely have abnormal bowel movements.
In your lifetime, have you had any abdominal surgeries?
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Yes: I had an appendectomy and/or a cholecystectomy
Yes: I had some other abdominal surgery
No
In the last 3 months, how often did you have hard or lumpy stools?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of times with pain
In the last 3 months, how often did you have fewer than three bowel movements a week without taking a laxative medication or enema?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of times with pain
In the last 3 months, how often did you strain during bowel movements?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of all bowel movement
In the last 3 months, how often did you have a feeling of incomplete emptying after bowel?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of all bowel movements
In the last 3 months, how often did you have a sensation that the stool could not be passed (was blocked) when having a bowel movement?
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of all bowel movements
In the last 3 months, how often did you press on or around your bottom, or remove stool with your finger, in order to have a bowel movement?
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0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of all bowel movements
Did any of the symptoms of constipation previously mentioned, begin more than 6 months ago?
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Yes
No
In the last 3 months, how often did you have mushy or watery stools that looked like Type 6 or 7 in the image below when you were not using drugs or other treatment for constipation?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Percent of all bowel movements
Did you have mushy and watery stools (like Type 6 or 7) when you were not using drugs or other treatment for constipation?
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Yes
No
How often did you have hard or lumpy stools, that look like Type 1 or 2 in the picture below?
* must provide value
0% (Never) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Always)
Did you have a gastric emptying test (test that measures how fast-food empties out of the stomach)?
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Yes
No
What was the test result?
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Normal
Abnormal (stomach emptied slower than normal)
Nausea (feeling sick to your stomach as if you were going to vomit or throw up)
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Retching (heaving as if to vomit, but nothing comes up)
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Vomiting
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Stomach fullness
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Not able to finish a normal-sized meal
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Feeling excessively full after meals
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Loss of appetite
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Bloating (feeling like you need to loosen your clothes)
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Stomach or belly visibly larger
* must provide value
Which of the following conditions have you been diagnosed with by a healthcare provider?
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Has a doctor ever told you that you have any of the following medical conditions?
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How was your Celiac Disease diagnosed?
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Are you currently experiencing rectal bleeding and fecal urgency?
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Yes
No
Are you currently taking a steroid (prednisone/ budesonide)?
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Yes
No
Are you currently taking a biologic and/or small molecule to control the ulcerative colitis (i.e. infliximab, adalimumab, golimumab, vedolizumab, ustekinumab, tofacitinib, upadacitinib, ozanimod, 6-mercaptopurine, azathioprine, methotrexate)?
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Yes
No
Do not know
Do you feel that your ulcerative colitis is not active at this time?
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Yes
No
Are you currently experiencing diarrhea, weight loss and/or abdominal pain?
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Yes
No
Are you currently taking a steroid (prednisone/ budesonide)?
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Yes
No
Do not know
Are you currently taking a biologic and/or small molecule to control the Crohn's disease (i.e. infliximab, adalimumab, certolizumab, vedolizumab, ustekinumab, rizankizumab, 6-mercaptopurine, azathioprine, methotrexate)?
* must provide value
Yes
No
Do not know
Do you feel that your Crohn's disease is not active at this time?
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Yes
No
Have you had bowel surgery for your Crohn's disease?
* must provide value
Yes
No
Are you currently experiencing diarrhea?
* must provide value
Yes
No
Are you currently taking a steroid (prednisone/ budesonide)?
* must provide value
Yes
No
Do not know
Are you taking any other biologic or small molecules to control the microscopic colitis (i.e. azathioprine, 6-mercaptopurine, vedolizumab, infliximab, adalimumab)
* must provide value
Yes
No
Do not know
Do you feel that your microscopic colitis is not active at this time?
* must provide value
Yes
No
Do you have any metal, implants, or devices in your body, such as IUDs or screws?
* must provide value
Yes
No
Have you had any surgeries in the past involving metal, implants, or devices, such as breast augmentation surgery or any orthopedic surgery?
* must provide value
Yes
No
Would you be able to provide documentation on the metal, implant, or device used?
* must provide value
Yes
No
Have you had any dental work in the past involving metal, such as permanent retainers, metal bars, or metal plates?
* must provide value
Yes
No
How old were you when you were diagnosed with Parkinson's disease?
* must provide value
Under 45 years old
45-65 years old
Over 65 years old
Do not know
The option "
What future studies would you be interested in participating in?
* must provide value
Do you own a smartphone, if so, what kind?
Apple iPhone
Android smartphone
Another smartphone
I do not own a smartphone
How many hours do you spend on your smartphone per day?
1-2
2-4
=>5
Do you actively use smart or interactive technologies (smart watches, apps, tablets)?
Yes
No
Other than a smartphone what smart technologies do you use? Please select all that apply:
Do you have access to Wi-Fi where you live?
Yes
No
How did you hear about the Gastrointestinal (GI) Registry?
* must provide value
UCLA Patient Portal (My Chart)
Social Media
Doctor or other Healthcare Professional
In Clinic advertisement (Fliers and Posters)
UCLA Newsletter
Television
Family member or friend
UCLA Website
Other
Rome III - Irritable Bowel Syndrome Criteria 1
View equation Rome III - Irritable Bowel Syndrome Criteria 2
View equation Rome III - Irritable Bowel Syndrome Criteria 3
View equation Rome III IBS Diagnosis / Functional Constipation Criteria 3
View equation Rome III - Functional Constipation Criteria 1
View equation Rome III - Functional Constipation Criteria 2
View equation Rome III - Functional Constipation Criteria 4
View equation Rome III - Functional Constipation Diagnosis
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