Fields marked with an * are required.

Are you filling out this screener on behalf of someone or for yourself? * Please select one... Myself Someone Else

{{ error }}

First Name *

{{ error }}

Last Name *

{{ error }}

Country * Please select one... USA Canada

{{ error }}

Phone Number (including area code) *

{{ error }}

Email 

{{ error }}

Date of Birth MM/DD/YYYY *

{{ error }}

ZIP or Postal Code *

{{ error }}

Do you believe you currently have, or are currently experiencing C. diff symptoms? * Please select one... Yes No

{{ error }}

Have you experienced an episode of C. diff in the past? * Please select one... Yes No

{{ error }}

Are you experiencing any of the following symptoms? *
Please select all that apply. Hold down CTRL to select more than one. Multiple Loose Stools (3 events or more within 24 hours) Foul Smelling Stools Temperature None of the above

{{ error }}

Have you taken antibiotics or been in the hospital within the last 6 months?
Please select all that apply. Hold down CTRL to select more than one. Yes – I have recently taken antibiotics Yes – I have recently been in hospital No

{{ error }}

Was this previous episode confirmed by a healthcare professional? Please select one... Yes No

{{ error }}

What prescription medications are you currently taking? *
Please list here or write 'none'. You don't need to list your Birth Control

{{ error }}

Have you been diagnosed with or suffer from any other conditions? *
If ‘yes’, please use the space provided below to list them.

{{ error }}

If female, are you currently pregnant or breastfeeding? Please select one... Yes No N/A - Male

{{ error }}

What is the best day/time to reach you via telephone (we know you are busy)? *

{{ error }}

Would you like to be contacted about taking part in a Clinical Trial? *

Yes

{{ error }}