Thank you for interest in Oshi Health, Inc.'s Virtual GI Symptom Management Pilot Program. This is a survey related to an email you received from Oshi Health, Inc. We expect this to take 5 minutes to complete. For further questions, reach out to researchcoordinator@oshihealth.com. 

All the information you provide in this survey will be kept confidential and will only be used to decide program eligibility

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* 1. What is your full name?

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* 2. Please provide your contact information so we can let you know if you've qualified for our program.

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* 3. Please enter your date of birth

Date

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* 4. Gender

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* 5. Please specify your ethnicity

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* 6. This offering is open only to those who currently reside in the United States (void in Alaska, Hawaii, Puerto Rico and all U.S. Territories and Possessions, and overseas military installations).
Do you currently live in the United States of America?

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* 7. What is your current body mass index (BMI)? To calculate your BMI, please use this BMI calculator

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* 8. Has a doctor ever diagnosed you with one (or more) of the following diseases?

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* 9. Are you currently or have you experienced within the last 2 months GI-related symptoms?

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* 10. Please select any of the following symptoms you have experienced currently or within the last 2 months:

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* 11. On average, when you are experiencing active symptoms, how often do they occur per week?

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* 12. On a scale of 1 - 10, how do your symptoms impact your daily activities?

1 - Doesn't impact my life at all 5 - Sometimes impacts my life 10- Severely impact daily activities
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i We adjusted the number you entered based on the slider’s scale.

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* 13. Have you taken or completed a course of antibiotic treatment or medication with the last 30 days to control your GI symptoms?

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* 14. If yes, can you specify which medications?

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* 15. Are you interested and committed to working with a registered dietitian (RD) to identify food triggers and implement healthy behaviors?

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* 16. Are you interested and committed to working with a health coach to identify food triggers and implement health behaviors?

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* 17. How did you learn about this program? (Please select all that apply)

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* 18. If referred by a provider or specialist, please specify the name of who referred you.

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