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GutMMAP Study Pre-Screening Questionnaire

Welcome!

We are collecting the following information to determine if you are eligible to participate in a research study on normal bacteria that live in the human gut and how it might influence the nutrients we get from the foods we eat. The information you provide here will be used to determine if you are eligible to participate in this study.

We will email you at the address you provide below within one week, to let you know if you are eligible or not eligible for the next step in the study. If you are not eligible, the data you provide here will not be used for research.

Thank you for your interest in our study.

Reach out to us at gutmmap@umd.edu with any questions, or visit our study website for more info.

First Name

* must provide value

Last Name

* must provide value

What name would you like our team to call you?

* must provide value

E-mail

* must provide value

Cell phone number

* must provide value

Age, in years

* must provide value

Height, in inches

* must provide value

Current weight, in pounds

* must provide value

BMI

View equation

Do you have any food allergies?

* must provide value

Yes

reset

Please list your food allergies.

(For GutMMAP Research Team) Review the individual's listed food allergies. Is the individual allergic to milk, eggs, tree nuts, peanuts, wheat, soybeans, or sesame?

If yes, mark "NO Phone Screen" and mark form complete. The individual is NOT eligible for a phone screen.
If no, mark "Phone Screen" and mark form complete. The individual is eligible for a phone screen.

Phone Screen

NO Phone Screen

reset

Have you ever had an anaphylactic or other serious allergy response to consuming any food or beverage?

* must provide value

Yes

reset

We may ask you to eat the following foods during this study. Please check the box next to any food that you are unwilling OR unable to eat for any reason.

Soy

Chicken

Beef

Yogurt

Cheese

Eggs

Wheat

Apples

Nuts

Something else

I would be willing and able to eat any of these foods.

Please list the foods you are unwilling or unable to consume.

Expand

(For GutMMAP Research Team) Review the individual's listed foods they are unwilling or unable to consume. Is the participant still able to complete the study?

If yes, mark "Phone Screen" and mark form complete. The individual is eligible for a phone screen.
If no, mark "NO Phone Screen" and mark form complete. The individual is NOT eligible for a phone screen.

Phone Screen

NO Phone Screen

reset

Have you ever been diagnosed with the following? (check all that apply)

* must provide value

Kidney disease

Liver disease

Crohn's Disease

Ulcerative colitis

Irritable bowel syndrome (IBS)

Celiac disease

Stroke

None of the above

Do you have a pacemaker, implanted defibrillator, or other implanted electronic device?

* must provide value

Yes

reset

Are you currently pregnant or lactating, planning to become pregnant in the next year, or within 3 months post-partum?

* must provide value

Yes

Not applicable

reset

Did you take an antacid or stomach acid reducing medication on most days in the past month?

* must provide value

Yes

reset

Have you taken an oral or intravenous antibiotic medication for any reason within the past month?

* must provide value

Yes

reset

Do you have intentions or plans to move away from the College Park area in the next year?

* must provide value

Yes

reset

How did you hear about this study?

* must provide value

Social media

Received a recruitment email

Paper flyer on campus

Paper flyer off campus

Personal recommendation

Face-to-face conversation

ResearchMatch

UMD Research website

Internet search

Other

reset

Please explain.

By submitting this form, I consent to the GutMMAP Research Team to collect, store and use my contact information for dietary study recruitment purposes.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.