Fields marked with an * are required.

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. By providing your phone number and clicking “Submit” below, you consent to receive messages, including SMS/MMS text messages, sent by or on behalf of AutoCruitment, with information about research studies for which you may be eligible. By clicking Submit, you also agree to our SMS Terms. 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.

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 for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested? *
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.

Yes

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Who are you interested in this study for? * Please select one… Myself My Spouse/Relative The Person I Care For Other

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First Name of the Patient *

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Last Name of the Patient *

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Date of Birth MM/DD/YYYY of the Patient *

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Zip Code or Postal Code of the Patient *

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Does the patient have upper limb spasticity, which is a condition that causes the muscles controlling the shoulder and elbow to become stiff or flexed, or twitch and move in a way that can't be controlled? * Please select one... Yes - upper limb spasticity No

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Is the patient’s upper limb spasticity due to a brain or spinal condition, such as a stroke, spinal cord injury, brain injury, cerebral palsy or multiple sclerosis? * Please select one... Yes No

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When was the patient diagnosed with the above brain or spinal condition? * Please select one... Less than 6 months ago 6+ months ago Unsure

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In the last 6 months, has the patient experienced a stroke, traumatic brain injury or a spinal cord injury? * Please select one... Yes No

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Has the patient been diagnosed (by a doctor) with any other medical conditions? *
(For example:

• Schizophrenia (a serious mental health condition that affects how people think, feel and behave)
• Cryoglobulinemia (abnormal proteins in the blood that may clump together below normal body temperature)
• Paroxysmal cold hemoglobinuria (autoimmune anemia in which red blood cells are destroyed after cold exposure)
• Cold urticaria (a rash that appears after exposure to cold)
• Raynaud's Disease
• ALS (a progressive neurological disorder))

Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

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Is the patient taking any medications to control/treat spasticity? *
(For example: Baclofen (oral or intrathecal/spinal pump), Tizanidine, Dantrolene sodium, Diazepam, Clonazepam)
Please list them below or type ‘none’.

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If female, is the patient currently pregnant, breastfeeding, or planning to become pregnant? * Please select one... Yes No N/A- Male

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Which racial or ethnic group(s) do you identify with? *
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

Another race or ethnicity

I prefer not to answer

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First Name of person to contact *

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Last Name of person to contact *

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Phone Number of person to contact *

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Alternate Phone Number of person to contact

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Email of person to contact (if you or the person you are signing up does not have an email address, please enter N/A). *

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What is the best day/time to reach you via telephone (we know you are busy)? You may also use this text box to include additional comments or information that may be relevant. *

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