Fields marked with an * are required.

Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

Yes

First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code or Postal Code *

What is your gender?

Female

Male

Prefer Not To Say

Have you been experiencing osteoarthritis in one of your shoulders? *

Yes - experiencing osteoarthritis

No

How many days per month do you experience pain in your shoulder due to osteoarthritis? *

Do you experience persistent pain in BOTH shoulders due to a diagnosed medical condition? *

No - pain in one shoulder only

Yes - pain in both shoulders

Unsure

Do you have any surgical hardware in your shoulder? *

Yes - surgical hardware

No

Surgical hardware includes plates, pins or screws.

Have you been diagnosed (by a doctor) with any other medical conditions? *
Please list here or write 'none'. (For example: rheumatoid arthritis, gout, lupus, inflammatory bowel disease, asthma, depression, psychiatric illness, COPD)
Please only include conditions which have been diagnosed by a doctor.

Have you been diagnosed (by a doctor) with any other chronic pain conditions? *

Yes - I was diagnosed with another chronic condition less than 1 month ago

Yes - I was diagnosed with another chronic condition more than 1 month ago

No

Chronic pain lasts for over three months and may come and go. It can happen anywhere in your body. This is separate from the pain you experience from your shoulder osteoarthritis.

Are you still experiencing pain from this chronic pain condition? *

Yes No

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

Please, enter your height below. *

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

Which racial or ethnic group(s) do you identify with? *
Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.
Please select all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Mediterranean (Greek/Italian/Portuguese/Spanish/etc)

Another race or ethnicity

I prefer not to answer

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

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible? To opt out, reply “STOP”. For customer care or support, text “HELP”. Message and data rates may apply. Message frequency varies. By clicking “Yes”, you also agree to our SMS Terms and Privacy Policy. *

Yes No

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.