Pre-screening Questionnaire

Moderate to Severe Atopic Dermatitis

Recruiting

Male/Female

18 - 60 years of age

Compensation Provided

Contact Information

Please enter your legal name, a valid phone number, and a valid email address where you can be contacted.

First Name

Last Name

Phone

Gender

Age

Preferred Language

Eligibility Questions

Please answer the following questions to determine your eligibility for this study.

Are you between 18 and 60 years of age?

Yes

Have you had moderate to severe eczema for at least 1 year?

Yes

Have you been diagnosed with Atopic Dermatitis?

Yes

Have you been unsuccessful treating your eczema with topical treatments or phototherapy?

Yes

Are you pregnant?

Yes

Do you suffer any other inflammatory diseases?

Yes

Do you have a history of cardiovascular disease?

Yes

Do you suffer severe, progressive, or uncontrolled signs or symptoms of hepatic, renal, hematological, gastrointestinal, endocrine, pulmonary, cardiovascular, neurological/ cerebral, or psychiatric disease?

Yes

Do you have other skin conditions?

Yes

Have you recently received treatment with allergen immunotherapy?

Yes

Have you recently received Phototherapy?

Yes

Do you have a history of substance abuse (drug or alcohol) problem?

Yes

You can call, email, or text me about current or future studies.

Thank you for taking the time to complete this Pre-screening Questionnaire!

We will contact you shortly. Please check your email for additional instructions.

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