Let's see if you're a good candidate for this new testing and treatment for IBS. Please fill out the following questions to the best of your knowledge.

Do any of the following conditions apply to the person seeking treatment? *

None of these conditions apply

One or more of these conditions apply

• Is the patient eight years old or younger?

• Are you pregnant?

• Do you have severe eczema all over or any significant rash on your back?

• Take any of the following immunosuppressive medications or any others within two weeks prior to or during the patch testing? Corticosteroid (cortisone)-containing, cyclosporine, mycophenylate mofetil, azathioprine, tacrolimus or others within these classes of medications?

• Ever see blood in your stools?

• Have unexplained fevers?

• Have you had unexplained/unintentional weight loss of more than 10 pounds in the past year?

Have you been diagnosed with irritable bowel syndrome (IBS) by a doctor or other health care provider? *

Yes

Do you experience occasional or frequent abdominal pain? *

Yes

Does your abdominal pain improve or worsen when having a bowel movement? *

Yes

When you experience abdominal pain, do your bowel movements become:

A. More often? *

Yes

B. Less often ? *

Yes

Do you experience occasional or frequent gas or bloating with no known underlying cause? *

Yes

Please leave any comments that you feel may be relevant:

When you experience abdominal pain, do your stools:

A. Get harder? *

Yes

B. Get softer? *

Yes

Please fill out your information below so that we can complete your automated screening. You will be given your results immediately.

Name *

Phone *

I understand that my responses are part of a pre-screening process and by submitting my phone number, I verify that the information given is true to the best of my knowledge. I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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Copyright © 2024 The IBS Test Centers, PC - All Rights Reserved.