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Autoimmune & Other Chronic Conditions Research Registry Survey

This is a patient registry for people with a variety of chronic health conditions. These conditions include optic neuritis, radiologically isolated syndrome, clinically isolated syndrome, multiple sclerosis, other neuroimmune conditions, other neurological conditions, other autoimmune conditions, mental health conditions, high blood pressure, obesity, high cholesterol, prediabetes, diabetes, insulin resistance, metabolic syndrome, heart disease, infertility, and other chronic diseases.

Please complete the survey below.

Thank you!

Thank you for your interest in our research! Completion of this survey will indicate your willingness to participate in the study.

If you agree to participate, please complete the survey below. It should take approximately five minutes to complete. You are free to leave questions unanswered if you prefer not to answer them.

If you have any questions about the research study itself, please contact the research team at MSDietStudy@healthcare.uiowa.edu or at 319-384-5002.

We invite you to participate in a research study. The purpose of the study is to create a registry of people who have been diagnosed with a neurologic, autoimmune, or other chronic health condition so that they can be contacted in the future for studies that may relate to their disease.

We are inviting you to be in this study because you may have been diagnosed with a neurologic, autoimmune, or other chronic health condition. You may have heard about our research registry online from a social media website, live feed, podcast, blog, online health summits/conferences, or other websites related to diet, health, lifestyle, and wellness. We may have obtained your name and address because you are being treated at the University of Iowa or have responded to a UI recruitment email. Approximately 10,000 people will take part in this study at the University of Iowa.

If you agree to participate, we would like you to complete a web-based survey that will collect basic information about you, such as your name, contact information, diagnosis, and other medical history and chronic conditions. This survey will take approximately five minutes to complete. You are free to leave questions unanswered if you prefer not to answer them. If you do not wish to participate in this registry, you do not need to complete the survey.

We will keep the information you provide confidential, however, federal regulatory agencies and the University of Iowa Institutional Review Board (a committee that reviews and approves research studies) may inspect and copy records pertaining to this research.

We will retain identifiable data from this survey for the purpose of contacting you about future studies that you may qualify for that relate to your neurologic, autoimmune, or other chronic health condition. Agreeing to participate in this research registry does not obligate you to participate in any other studies. You would sign a consent form for any other studies. If we write a report about this study we will do so in such a way that you cannot be identified.

There is a small risk of breach of confidentiality by participating in this study. There are no other known risks from being in this study, and you will not benefit personally.

You will not have any additional costs for being in this research study.

You will not be paid for being in this research study.

Taking part in this research study is completely voluntary. If you decide not to be in this study, or if you stop participating at any time, you won't be penalized or lose any benefits for which you otherwise qualify.

If you have any questions about the research study itself, please contact:
MS Diet Study Team
200 Hawkins Drive
Iowa City, IA 52242
(319)-384-5002

If you experience a research-related injury, please contact:
Mary Ehlinger
200 Hawkins Drive
Iowa City, IA 52242

If you have questions about the rights of research subjects, please contact the Human Subjects Office, 105 Hardin Library for the Health Sciences, 600 Newton Rd, The University of Iowa, Iowa City, IA 52242-1098, (319) 335-6564, or e-mail irb@uiowa.edu. To offer input about your experiences as a research subject or to speak to someone other than the research staff, call the Human Subjects Office at the number above.

Thank you very much for your consideration. Completing the survey below will indicate your willingness to participate in the study.

Sincerely,

Dr. Terry Wahls, MD, IFMCP, FACP

Clinical Professor of Medicine
Division General Internal Medicine
Secondary appointments in Neurology, Epidemiology

Demographics date

* must provide value

M-D-Y

First name

* must provide value

Middle name

Last name

* must provide value

Biological sex

* must provide value

Male

Female

reset

Date Of Birth

* must provide value

M-D-Y

Current age

View equation

Location

* must provide value

United States Address

International Address (Outside Unite States)

reset

Street address

* must provide value

Street address or P.O. box number

* must provide value

City

* must provide value

City, town, or principle subdivision such as province

* must provide value

State

* must provide value

State or County

* must provide value

Zip code

* must provide value

Postal Code

* must provide value

Country

* must provide value

Mobile phone number

* must provide value

Mobile number

Home phone number

May we contact you via text message?

* must provide value

Yes

reset

May we contact you at work?

Yes

reset

Work phone

Work phone number

* must provide value

Confirm email

* must provide value

Emails do not match. Please revise

Alternate email

Have you been diagnosed with a neurologic, autoimmune, or other chronic health condition?

Yes

reset

If you do not have a neurologic, autoimmune, or other chronic health condition and would like to participate in a healthy control research registry please contact the study team at msdietstudy@healthcare.uiowa.edu.

What neurologic or autoimmune conditions have you been diagnosed with? Select as many as apply.

None

Optic neuritis

Clinically isolated syndrome

Radiologically isolated syndrome

Multiple sclerosis

Other neurologic disease or condition involving the nervous system

Fibromyalgia

Rheumatoid Arthritis

Psoriatic Arthritis

Systemic lupus erythematosus

Inflammatory bowel disease (IBD), Ulcerative colitis, or Crohn's disease

Other autoimmune disease

Post-acute sequela of COVID-19 (PASC or Long covid)

Please provide the date (or approximate) that your physician diagnosed you with multiple sclerosis.

M-D-Y

What other chronic conditions have you been diagnosed with? Select as many as apply.

None

High blood pressure

High cholesterol

Pre-diabetes or diabetes

Insulin resistance

Metabolic Syndrome

Obesity

Heart disease

Pelvic pain, endometriosis, or infertility

Mental health symptoms or diagnoses

History of cancer

Other chronic disease or condition

Have you been to UIHC before?

* must provide value

Yes

Don't know

reset

Do you have a smart phone?

* must provide value

Yes

reset

Are you willing to complete study questionnaires online on your home computer, tablet, smart phone, etc.?

* must provide value

Yes

reset

How did you hear about the study?

* must provide value

National MS Society

Terry Wahls website

Social Media - Facebook, Instagram, Twitter

Clinicaltrials.gov

Terry Wahls email (newsletter, roundup, etc.)

Referral - friend / family

Referral - practitioner (doctor, PT, RD, health coach, chiropractor, etc.)

Podcast / webinar / other website

Other; please explain below

Please describe how you heard about the study or any comments

Expand

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