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FIND OUT MORE ABOUT ParticipatING in AN eczema research study

Thank you for participating in this UCSF Eczema Research Study Pre-Screening Questionnaire. Completing this questionnaire is entirely voluntary.

 

If you decide to complete this questionnaire, the information you provide us will be shared with UCSF, the sponsor of the study, as well as its research coordinators, partners, collaborators, and contractors. We collect this information to help pre-screen potential candidates before forwarding the relevant information to UCSF, which will conduct the full screening procedure and informed consent process before confirming your eligibility to enroll in the study. Sharing your information does not guarantee that you will be eligible or selected for participation in the study.

 

Filling out the survey below means that you consent to our Terms and Conditions and Privacy Policy. 

Have you been diagnosed with atopic dermatitis (eczema) by a physician?
Yes
No
How would you describe your eczema overall?
Mild
Moderate
Severe
Do you have an active rash?
Yes
No
Are you currently being treated for your eczema? If so, how?
If not currently on Dupixent, have you ever been treated with Dupixent in the past?
Yes
No
Have you used any other biologic medication in the past 12 weeks?
Yes
No
Have you had phototherapy or a systemic eczema medication (other than Dupixent) in the past 4 weeks?
Yes
No
Are you currently enrolled in any other research study involving a drug, biologic, or other therapy?
Yes
No
Do you have any allergy to lidocaine, novocaine, or a reaction to epinephrine?
Yes
No
Medical History: Do any of the following apply to you? (check all that apply)
The study requires one in-person visit at UCSF Dermatology lasting about 40 minutes. Are you able to attend?
Yes
No
An optional brief second visit may be needed to remove stitches (~2 weeks later). Are you able to return, or would you prefer absorbable sutures / a take-home removal kit?
Can return for second visit
Prefer absorbable sutures / at-home kit
Are you able to get to UCSF Dermatology at 1701 Divisadero Street, San Francisco for your visit(s)?
Yes
No
Needs assistance / more information
Are you able to complete the informed consent process in English?
Yes
No
Interpreter Needed
I agree to the Terms and Conditions and Privacy Policy
I agree
I do not agree (Please do not click Continue)
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