Ulcerative Colitis (UC) Research Study Screener

Full Name

Email Address

Phone Number

Date of Birth

City and State

May we contact you about future studies?

Yes No

What types of studies would you be interested in?

Have you been diagnosed with ulcerative colitis (UC) for at least 3 months?

Yes No

Has your UC affected at least 15 cm of your colon (shown on a past colonoscopy)?

Yes No Not sure

Are you currently experiencing UC symptoms (such as diarrhea, blood in stool, or abdominal pain)?

Yes No

Are you currently taking mesalamine or sulfasalazine for UC?

Yes No

Do you have any of the following?
○ Crohn’s disease or indeterminate colitis
○ Chronic kidney disease
○ Severe liver disease
○ Diabetes, lupus, or other autoimmune conditions
○ History of cancer in the last 5 years
○ Serious heart conditions (arrhythmia, heart failure, stroke, or coronary artery disease)

Yes No

Are you currently pregnant or breastfeeding?

Yes No

Have you had surgery to remove part of your colon, or are you likely to need colectomy soon?

Yes No

Have you taken any of the following in the past 6 weeks?
○ Steroids (prednisone)
○ Immunosuppressants (azathioprine, 6-MP, etc.)
○ Biologics (anti-TNF, vedolizumab, etc.)
○ JAK inhibitors (tofacitinib, upadacitinib)
○ High-dose vitamin C or other experimental drugs

Yes No

Are you currently enrolled in another clinical trial or have you participated in one in the last 30 days?

Yes No