Atopic Dermatitis Study

Fields marked with an * are required.

First Name *

Last Name *

Phone number *

Date of Birth DD/MM/YYYY *

ZIP or Postal Code *

Have you been diagnosed, by a doctor, with Atopic Dermatitis/Atopic Eczema? *

How long have you suffered from Atopic Dermatitis/Eczema? *

Does your Atopic Dermatitis/Eczema cover 10%, or more than 10% of the body? *
Note: The palm of your hand is approximately 1% of your body’s surface area. The front and back of each arm and hand are 10% of the body’s surface area. The chest and stomach are 13% of the body’s surface area. The back is 13% of the body’s surface area. The buttocks are 5% of the body’s surface area. The head or neck is 1%.

Have you tried using creams, ointments or other topical (medications applied to the skin) medications to treat your Atopic Dermatitis/Eczema? *

Have these creams, ointments or other topical (medications applied to the skin) medications improved your symptoms by at least 50%, or are you still in need of additional treatment for your Atopic Dermatitis/Atopic Eczema? *

Have you been diagnosed (by a doctor) with any other medical conditions? *
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

Are you taking any medications for your Atopic Dermatitis/Eczema or other health conditions? *
Please list them below or type ‘none’.

Please, select your height from the dropdown below. *

How much do you weigh in Lbs (pounds)? *

If female, are you currently pregnant or breastfeeding?

Are you willing to use contraception during the study, and for at least 60 days after the study has ended? *

Would you like to be contacted about taking part in a Clinical Trial? *

Yes

What is the best day/time to reach you via telephone (we know you are busy)? *

The information you are providing here will only be used to match you to a clinical research study in the potential participant’s area and contact you to see if you would like to participate. Please note the information you enter will be kept private, except when ordered by law, and only accessible to our Clinical Research Partners and affiliates and applicable regulatory agencies. If you have any questions regarding the handling of the information you have provided to autocruitment.com, or if you would like to make any changes, please contact us at info@autocruitment.com.