Mabu Pilot Screening
This short questionnaire will help Catalia Health to better understand a bit about you and your health in order to schedule you into an appropriate pilot group.

Please don't be discouraged if you're not contacted to participate right away; we will keep your interest on file and will reach out in the future.

By submitting this form you consent to sending some health-related information to Catalia Health. We strive to protect our patients’ information and will only use this information to determine your eligibility for the program and to better understand where you are on the spectrum of health and disease. The information will not be used for any other purposes.

Email address *
What is your age? *
Your answer
What U.S. state or other country do you currently live in? *
Your answer
Please indicate your ethnicity: *
What gender do you identify with?
Do you have a chronic illness? *
Please list the name(s) of your chronic condition(s) below. If you do not have any chronic conditions, please type "N/A." *
Your answer
How long ago were you diagnosed with this/these condition(s)? If you do not have any chronic conditions, please type "N/A." *
Your answer
Why are you interested in participating in this pilot research?
Your answer
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