EXIT Doctor Consultation Application HMT Consultation Please fill out the answers to the questions below in order to apply for an HMT consultation with a specialist. Not all applications will be accepted. We will try to accept as many applications for patient consultations as possible. 請回答以下的問題,以便向腸胃科專家申請免費諮詢。 並非所有的申請都會被接納,我們會竭盡所能地接受病人的申請。 OK Question Title * 1. Please provide your contact information 請提供您的聯繫方式 Name 姓名 * City 城市 Email Address 電郵地址 * Phone Number 聯絡電話 * OK Question Title * 2. Please confirm your email address 請再次確認您的電郵地址 OK Question Title * 3. How do you prefer to be contacted? 您希望我們透過什麼方式與您聯繫? Email 電子郵件 Mobile Phone 手機號碼 WhatsApp號碼 OK Question Title * 4. Do you have a gut or bowel disease diagnosis? 您曾接受腸道或腸道疾病的診斷嗎? Yes有 No沒有 OK Question Title * 5. If Yes, what diagnosis have you been given? 若有,您接受了什麼診斷? Irritable Bowel Syndrome 腸易激綜合症 (IBS) Chronic Constipation 慢性便秘 Ulcerative Colitis 潰瘍性結腸炎 (UC) Crohn's Disease 克隆氏症 (CD) Severe Bloating, Gas, Flatulence 嚴重腫脹,腸胃氣脹 Other (please specify) 其他(請註明) OK Question Title * 6. How did you first hear about Human Microbiota Transplant (HMT) 您是如何得知人類菌群移植 (HMT)? OK Question Title * 7. How likely are you to accept HMT if prescribed by a doctor 若醫生處方HMT,您會否願意接受? Very Unlikely 非常不可能 Undecided 未能決定 Very Likely 非常願意 Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 8. When would you be available for a GI-Consultation 您願意在以下哪一天參加腸胃科醫生諮詢? This month月 Next month 月 Both Dates are OK 以上兩天都可以 Not Available, available other days, please specify:都不能出席;如有其他日期,請註明: OK DONE - QUESTIONS FINISHED - SUBMIT ANSWERS 完成 - 問題完成 - 提交