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Atopic Dermatitis Study
Got Atopic Dermatitis or Eczema? You may qualify for a research study.
Below is a pre-screening survey to help us determine your qualification in one of our studies. You may stop the survey at anytime. All information provided is confidential.
1.
What is your first name?
2.
What is your last name?
3.
Phone Number:
4.
Email:
5.
Are you at least 18 years of age?
Yes
No
6.
Have you had a medical diagnosis of atopic dermatitis for at least 1 year?
Yes
No
7.
If female, are you pregnant or planning a pregnancy or nursing?
Yes
No
8.
On a scale from 0-10 where 0 is no itch at all and 10 is the worst itch imaginable, how much does your eczema/atopic dermatitis itch?
0
1
2
3
4
5
6
7
8
9
10
9.
On an average day how much Eczema/Atopic Dermatitis do you visibly have covering your Body Surface Area (your entire body)? (Using your palm to measure, Your palm=1% Body Surface Area)
I have less than 5% Eczema/Atopic Dermatitis
I have less than 10% Eczema/Atopic Dermatitis
I have greater than 10% Eczema/Atopic Dermatitis
I have greater than 30% Eczema/Atopic Dermatitis
10.
Which therapies are you currently using for your Atopic Dermatitis or Eczema?
Topical Medications (Over the counter)
Topical Medications (Prescription)
Antihistamines
Tablets
None
11.
Have you had problems treating your eczema/atopic dermatitis with creams or ointments containing steroids, either because it did not work well enough or because of side effects?
Yes
No
12.
In a clinical research trial, would you be willing to receive injections to treat your eczema/atopic dermatitis?
Yes
No
13.
Have you participated in a research study within the last 30 days?
Yes
No