Advocacy Day: Patient Stories

1. Would you like to include your name in the letter? *This question is required.

• Yes, my name is... Please enter an 'other' value for this selection.
• No, I would like to remain anonymous please

3. What is your gender? *This question is required.

• Male
• Female
• Transgender Male
• Transgender Female
• Gender Variant / Non-conforming
• Other - Write In Please enter an 'other' value for this selection.
• Prefer not to answer

4. What is your ethnicity? *This question is required.

• Asian
• Native Hawaiian or Other Pacific Islander
• Black/African-American
• White
• Hispanic/Latino
• American Indian/Alaska Native
• Other - Write In Please enter an 'other' value for this selection.
• Prefer not to answer

5. What is your primary gastrointestinal (GI) diagnosis? (Choose one) *This question is required.

• Achalasia
• Acid Reflux
• Barrett's Esophagus
• Celiac Disease
• Constipation
• Crohn's Disease
• Cyclic Vomiting Syndrome (CVS)
• Diarrhea
• Dyspepsia
• Eosinophilic Gastroenteritis
• Fecal Incontinence
• Gastroparesis
• GERD
• Hirschsprung's Disease
• Intestinal Pseudo Obstruction
• Irritable Bowel Syndrome (IBS)
• Refractory GERD ( rGERD)
• Scleroderma
• Short Bowel Syndrome
• Small Intestinal Bacterial Overgrowth (SIBO)
• Superior Mesenteric Artery (SMA) Syndrome
• Other - Write In (Required) Please enter an 'other' value for this selection.

6. What other gastrointestinal (GI) diagnoses do you have? (Check all that apply) *This question is required.

• Achalasia
• Acid Reflux
• Barrett's Esophagus
• Celiac Disease
• Constipation
• Crohn's Disease
• Cyclic Vomiting Syndrome (CVS)
• Diarrhea
• Dyspepsia
• Eosinophilic Gastroenteritis
• Fecal Incontinence
• Gastroparesis
• GERD
• Hirschsprung's Disease
• Intestinal Pseudo Obstruction
• Irritable Bowel Syndrome (IBS)
• Refractory GERD ( rGERD)
• Scleroderma
• Short Bowel Syndrome
• Small Intestinal Bacterial Overgrowth (SIBO)
• Superior Mesenteric Artery (SMA) Syndrome
• Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.
• None

7. Do you have any other diagnosis unrelated to GI? *This question is required.

• Yes- Write In Please enter an 'other' value for this selection.
• No
• I would prefer not to say