參與炎症性腸病及腸道微生物栘植研究 Join an IBD & FMT Study

參與炎症性腸病及腸道微生物栘植研究 Join an IBD & FMT Study

香港中文大學腸胃科現正招募合適人士參與研究，有興趣人士請填寫以下表格!
你所提供的資料會用於有關香港中文大學炎症性腸病及腸道微生物研究，亦作日後聯絡之用，只有獲本研究部門授權人員方可查閱。你遞交表格後，如欲更正或查詢個人資料的使用，請與我們聯絡。
CUHK Gastrointestinal Team is now recruiting participants for various studies. If you are interested to participate, please fill in the following form!
We will use your information for IBD and FMT research. It will also be used for future contact. Only those who are authorised by this Department will have access to such information. For correction of or access to personal data collected by means of this form, please contact us.

姓名 Name 姓名 Name * 姓氏名字
性別 Gender

性別 Gender 男 Male 女 Female
出生日期 Date of birth 出生日期 Date of birth / 日 / 月西元年
聯絡電話 Phone
電郵地址 Email
本人有以下情況 I am now︰ *

本人有以下情況 I am now︰患有克隆氏症 diagnosed with Crohn’s Disease 患有潰瘍性結腸炎症 diagnosed with ulcerative colitis 患有炎症性腸病但不確定類型 diagnosed with inflammatory bowel disease but do not know which type 患有腸易激綜合症 diagnosed with irritable bowel syndrome 現正懷孕 pregnant 肥胖及患有二型糖尿病 obese and diagnosed with type II diabetes 身體狀況良好並希望成為研究志願者 in a healthy state and would like to be a research volunteer subject 其他 others 其他 others
查詢 Enquiries
我同意I agree

我同意I agree 收到有關香港中文大學其他研究的資訊 receive information related to other research from the CUHK 收到香港中文大學的問卷調查, 健康講座及其他教育資訊 receive survey and information related to health talk and education from the CUHK
此為防止機器人的機制，請回答問題。
What is "one hundred" as a number?
Disclaimer The personal data collected will be used by Institute of Digestive Disease (IDD), Faculty of Medicine (MEDT_IDD) and the authorised personnel for processing captioned purposes only. All personal data you provided will not be disclosed to any third parties unless with your prior consent.