Fields marked with an * are required.

First Name *

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Last Name *

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Phone Number *

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Email 

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Date of Birth MM/DD/YYYY *

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Zip Code or Postal Code *

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Are you Male or Female? Please select one... Male Female Prefer not to say

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Have you been diagnosed with Atopic Dermatitis/Eczema? * Please select one... Yes – I have Atopic Dermatitis/Eczema No

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How long have you suffered from Atopic Dermatitis/Eczema? * Please select one... Less than one year More than one year I don't know

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Does your Atopic Dermatitis/Eczema cover 10%, or more than 10% of the body? *
Note: The palm of your hand (no fingers) 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%. Please select one... Yes – I have Atopic Dermatitis on more than 10% of my body No

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Do you have any other major health conditions? *
Please list them below, or type ‘none’.

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Have you received a vaccine for smallpox, chickenpox, measles, shingles, rotavirus, herpes, polio or yellow fever in the last 12 weeks? * Please select one... Yes No

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Have you received a vaccine for Meningococcal disease (to protect you from becoming infected with bacteria that cause meningitis) in the past 4 years? *
(Names for these vaccines include Menactra®, Menveo®, Bexsero®, Trumenba®) Please select one... Yes No Unsure

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Have you received a vaccine for prevention of Tetanus in the past 5 years? *
(Names for these vaccines include Tenivac®, Boostrix®, Adacel®) Please select one... Yes No Unsure

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Participation in this study requires you to take 2 different commonly used, FDA approved, vaccines (TDAP and MCV). Are you willing to receive these vaccinations as required by the study? * Please select one... Yes No I'm not sure - I would need more information

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Have you been diagnosed with cancer (not including cancer of the skin or cervix) within the past 5 years? * Please select one... Yes - I have been diagnosed with cancer No

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Are you HIV positive? * Please select one... Yes - I am HIV positive No

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Do you have chronic or active hepatitis? * Please select one... Yes - I have hepatitis No

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Are you taking any medications for atopic dermatitis? *
Please list them below, or type ‘none’.

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Are you taking any medications for other health conditions? *
Please list them below, or type ‘none’.

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If female, are you currently pregnant, breastfeeding or planning to become pregnant in the next 15 months? Please select one... Yes No N/A - Male

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Are you currently enrolled or have you participated in a clinical trial within the last 30 days? * Please select one... Yes No

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

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Would you like to be contacted about taking part in a Clinical Trial that you may qualify for? *

Yes

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