Step 3 Consuli Survey 1/5/2021

We will email you matching studies and offer to this email.

Tell us more about yourself

Take a couple minutes to answer the questions below. Once you're done with this step, you'll be on the books to get SmartMatched™ with opportunities relevant to you. No information will be shared with any third party without your consent.

  • Location:
    • Street Address
    • Street Address Line 2
    • City
    • State (Please Select, Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming)
    • Zip Code

We will use this location to match you with studies and offers nearby. You can edit this information in the future.

  • Mobile Number:
    • Area Code
    • Phone Number

A valid mobile number is required and may be used for authentication and other member communications. Providing a mobile number here is an opt-in to receive messages, although you can always opt-out of SMS communications from your device.

  • Gender (changed to multiple choice property, hide this option):
    • Female
    • Male
    • Transgender female
    • Transgender male
    • Transgender
    • Genderqueer/Gender Non-Conforming
    • Questioning
    • I prefer not to say
    • Custom

We are asking for this information so we can better match you with the studies available. We will never display information about you publicly without your consent. If you would like to tell us more about your identity, please use our "custom" option to elaborate.

  • Select one or more options that reflect your gender:
    • Female
    • Male
    • Transgender female
    • Transgender male
    • Transgender
    • Genderqueer/Gender Non-Conforming
    • Questioning
    • I prefer not to say
    • Custom

We are asking for this information so we can better match you with the studies and trials available. We will never display information about you publicly without your consent. If you would like to tell us more about your identity, please use our "custom" option to elaborate.

  • What sex were you assigned at birth?

    • Male
    • Female
    • Intersex
    • Prefer not to answer

  • Birthdate:

    • /Month
    • /Day
    • Year

We will never display this information publicly.

  • Ethnicity (Select all that apply):
    • American Indian or Alaska Native
    • Asian
    • Black or African American
    • Hispanic or Latino
    • Native Hawaiian or Other Pacific Islander
    • White
    • I prefer not to specify
    • Other

At Consuli, we are committed to making everyone feel welcome, safe, and respected. If you do not see an option here that matches your ethnicity please use our "other" option and we will match you to studies using that information.

  • Please indicate your COVID-19 Diagnosis:

    • Active Diagnosis
    • Past Diagnosis
    • Never Diagnosed

  • How many days have passed since your diagnosis?

    • Days Since Diagnosis

  • Have you experienced covid-like symptoms and believe that you had / have COVID-19?

    • Yes
    • No

  • Are you experiencing long-term COVID-19 symptoms?

    • Yes
    • No

  • Have you experienced neurological symptoms for 3 or more months that caused you to be seen by a neurologist?

    • Yes
    • No

  • How many months have you had symptoms for?

    • Months

  • Were you previously hospitalized due to COVID-19?

    • Yes
    • No

  • Have you ever received any of the following treatments for COVID-19 complications?

    • Mechanical ventilation
    • Supplemental oxygen
    • None of the above

Check all that apply.

  • Do you have a confirmed diagnosis of Sickle Cell disease?
    • Yes
    • No

A Sickle Cell disease diagnosis can be characterized by having HbSS or Sickle Beta Thalassemia (Sickle Cell anemia).

  • Have you ever been diagnosed by a healthcare professional with any of the following medical conditions? (Select all that apply):

    • Alzheimer's disease
    • Asthma
    • Chronic Respiratory Diseases
    • Cirrhosis
    • Crohn's Disease
    • COPD
    • Dementia
    • Diabetes
    • Heart Failure
    • Hepatitis B or C
    • High Blood Pressure
    • HIV
    • Kidney Disease
    • Lung Cancer
    • Multiple Sclerosis
    • Ulcerative Colitis
    • None of the above
    • Other

  • Have you ever been diagnosed by a healthcare professional with any of the following medical conditions (Select all that apply)? Your answers are confidential:

    • High blood pressure (hypertension)
    • High cholesterol
    • Heart disease
    • Stroke
    • Diabetes (Type 1 or Type 2)
    • Obesity
    • Asthma
    • Chronic obstructive pulmonary disease (COPD)
    • Depression
    • Anxiety disorder
    • Bipolar disorder
    • PTSD
    • Epilepsy or seizure disorder
    • Dementia or Alzheimer’s disease
    • Parkinson’s disease
    • Arthritis (e.g., osteoarthritis, rheumatoid arthritis)
    • Chronic back pain
    • Lupus
    • Multiple sclerosis
    • Crohn’s disease or ulcerative colitis
    • Cancer (any type)
    • None of the above
    • Prefer not to say
    • Other

  • Are you currently pregnant or breastfeeding?

    • Yes
    • No
    • Not applicable

  • Please indicate your occupation:

    • Front-line healthcare worker
    • Other type of healthcare provider
    • College student
    • Prefer not to answer
    • Other

  • Do you own a smartwatch?

    • Yes
    • No

  • Do you currently own or use any of the following smart wearable devices (Select all that apply):

    • Apple Watch
    • Samsung Galaxy Watch
    • Garmin smartwatch
    • Google Pixel Watch
    • Oura Ring
    • Fitbit
    • MiaoMiao Smart Reader
    • WHOOP band
    • BioStrap
    • Prefer not to answer
    • I do not own or use any smart wearable devices
    • Other

  • Do you have access to the internet?

    • Yes
    • No

  • Have you ever used 23andMe for DNA testing?

    • Yes
    • No

  • Would you like to consider participating in a clinical trial or study?

    • Yes
    • No

  • What types of studies would you like to get email alerts about?

    • Vaccine trials
    • COVID-19 treatment & recovery studies
    • Data studies
    • Other studies
    • All of the above
    • None

Check all that apply.

  • How did you hear about us?

    • Please Select (Consuli, Aila, Alice Perlowski, American Sickle Cell Anemia Association, Angela Reiersen, As One Foundation, Blooming Magnolia, Body Politic, Covid Care Group, Covid Wellness, Cynthia Adinig, Data Union, Dr. David Putrino, Dr. Mari Mitrani, Dr. Robi Tamargo, Elle Seibert, Long Covid Alliance, Maya McNulty, Mount Sinai, Mymee, None of the above, Organicell, Other, Pandemic Patients, Scripps Translational Research Institute, Shelby Hedgecock, Sick Cells, Sickle Cell 101, Sickle Cell Anemia Disease Facebook Group, Sickle Cell Community Consortium, Sickle Cell Disease Association of America, Sickle Cell Disease Association, Michigan Chapter, Sickle Cell Disease Foundation, Sickle Cell Reproductive Health Education Directive, Sickle Cell Society, Sickle Cell Unite, Sickle Cell Warriors, Solve ME/CFS, Wail of a Tale)

  • What platform did you hear about us on?

    • Please Select (Clubhouse, Email, Facebook, Instagram, LinkedIn, Snapchat, Twitter, TikTok, YouTube, Other)

  • Did you hear about us from a Patient Advocate? If so, please provide their name.

  • UniqueID

  • SMS Confirmation widget

Confirm
ConfirmTry-Again

  • Submit