參與炎症性腸病或腸道微生物研究 Interested in Joining Study

參與炎症性腸病或腸道微生物研究 Interested in Joining Study

香港中文大學腸胃科現正招募不同人士參與研究，有興趣人士可填寫以下表格。
你所提供的資料會用於有關香港中文大學炎症性腸病或腸道微生物研究，亦作日後聯絡之用，只有獲本研究部門授權人員方可查閱。遞交表格後，如符合現正進行的研究計劃，我們將與你聯絡。
你可能需要回來沙田威爾斯親王醫院參加研究計劃。

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 or Microbiota research. It will also be used for future contact. Only those who are authorised by this Department will have access to such information. If you fulfil the criteria of currently conducting study/studies, we will contact you.
You may need to come to Prince of Wales Hospital, Shatin to enroll in the study.

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。
In the number 73628, what is the 4th digit?
Disclaimer The personal data collected will be used by Institute of Digestive Disease (IDD), Faculty of Medicine (MEDT_IDD) and authorised personnel for processing the captioned purposes in accordance with relevant provisions of the Personal Data (Privacy) Ordinance.