Full Name

Email Address

Zip code (or country if outside the U.S.)

Patient Age Range Patient Age Range Under 18 18-24 25-34 35-44 45-54 55-64 65+

Which digestive disease(s) have you or your loved one been diagnosed with? (Select all that apply) Which digestive disease(s) have you or your loved one been diagnosed with? (Select all that apply) Crohn’s disease Ulcerative colitis Celiac disease Irritable bowel syndrome (IBS) Gastroesophageal reflux disease (GERD) Liver disease (please specify) Pancreatic disease (please specify) Gallbladder disease Digestive cancers (please specify) Obesity-related disease (please specify) Other (please specify) I have not been diagnosed with a digestive disease Prefer not to say

More info on my diagnoses (optional)

Healthcare provider(s) name(s)

Tell us your story about positive communication experiences with your care team and how it impacted your disease management. Tell us your story about positive communication experiences with your care team and how it impacted your disease management.

My story...