Crohn's Disease & HUMIRA® (adalimumab) Information

First Name*

Last Name*

Email Address*

We ask for your email address so that we can send you information about your condition and HUMIRA.

Street Address*

We ask for your mailing address so that we can send you information about your condition and HUMIRA.

Street Address 2 (optional)

City*

State*

ZIP Code*

Phone Number

Date of Birth*

MM/DD/YYYY

We ask for your DOB to ensure that you're over 18 and to help us recognize your registration record.

Gender

1. What condition(s) have you been diagnosed with?*

Crohn's disease

Unsure

1a. When were you diagnosed?*

MM/YYYY

2. Are you currently treating your condition(s)?

3. Have you previously treated your condition(s)?

4. How often do you experience Crohn's symptoms?*

Every day

Weekly

Monthly

Rarely

5. How likely are you to talk to your gastroenterologist about a different treatment for your Crohn's disease?*

I'm planning on it

I'm considering it

I'm not ready yet

If so, when?*

MM/YYYY

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