Fibromyalgia Clinical Trial Study Pre-Screener
Demographics
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Middle Name
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Age:
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Height (inches)
Weight (pounds)
Contact Number:
-
Area Code
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Address:
Street Address
Street Address Line 2
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Postal / Zip Code
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United States
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Country
Eligibility:
Have you ever been diagnosed with Fibromyalgia?
Yes
No
No, but I think I have it.
Not sure, but I have symptoms,
If yes, date of diagnosis:
-
Month
-
Day
Year
Date
Have you experienced widespread pain, present at similar level for at least 3 months?
Yes
No
On the scale of 1-10, how bad has your pain been in the past week (on average)?
1
2
3
4
5
6
7
8
9
10
Best
Worst
1 is Best, 10 is Worst
Have you ever taken an investigational drug or participated in a research study?
Yes
No
If so, when and for what reason?
Are you in the process of applying for a work disability claim?
Yes
No
Have you taken cyclobenzaprine before?
Yes
No
If female, are you able to become pregnant?
Yes
No
If no, list reason. If yes, describe what forms of birth control you are currently taking (i.e. condoms with spermicide, oral birth control tablets, etc.)
Do you smoke cigarettes?
Yes
No
If yes, how many packs of cigarettes per week?
less than 1
1-2
2-3
3-5
6-7
8-14
over 14
Have you used oral tobacco (chewing, dipping tobacco, or betel nut in the past 6 months)?
Yes
No
Do you drink alcohol?
Yes
No
If yes, how many drinks per week?
0-3
3-5
5-7
8-14
Over 14
Do you use THC products recreationally or for a medical reason?
Yes
No
If so, please tell us how often and which form of THC products? (marijuana, edibles, vape, oils, etc)
Medical History
Please list any medical history that applies to you and include when you were diagnosed, and if the condition is still present and controlled or uncontrolled.
Cardiovascular (e.g., MI (heart attack) chest pain, arrhythmia, heart-block, vasculitis, heart failure, hypertension, abnormal Electrocardiogram results, heart defect, etc.)
Gastrointestinal (e.g., irritable bowel syndrome, gastrointestinal surgery, ulcer, GERD, etc.)
Hepatic (e.g., hepatitis, jaundice, other liver disease, etc.)
Endocrine (e.g., diabetes, hyper-or hypothyroidism, untreated hyperparathyroidism.)
Genitourinary (e.g., kidney problems, bladder problems, reproductive, etc.)
Musculoskeletal (e.g., rheumatoid arthritis, osteoarthritis, lupus, bursitis, tendonitis, rheumatoid arthritis, disc disease, ankylosing spondylitis, psoriatic arthritis, complex regional pain syndrome, failed back surgery syndrome, any type of systemic autoimmune disease, gout (list most recent attack of gout), etc.)
Neurological (e.g., history of seizures, head injuries, loss of consciousness, tremors, migraines, diabetic neuropathy, etc.)
Psychiatric (e.g., mania, psychosis, depression, anxiety, schizophrenia, bipolar disorder, schizoaffective disorder, drug or alcohol abuse within the past year, suicide attempts within the past 2 years, other psychotic disorders, shift-work disorder etc.)
Respiratory (e.g., sleep apnea, cataplexy, periodic involuntary limb movement disorder, allergies, asthma, narcolepsy, etc.)
Other (e.g., cancer, surgeries, eye problems, uncontrolled narrowed glaucoma, HIV, use of chewing tobacco or dip in the last 6 months, etc.)
Are you currently taking any medications? Please include any vitamins or supplements.
NAME OF DRUG
DOSE
TIMES/DAY
START DATE
INDICATION
MEDICATION 1:
MEDICATION 2:
MEDICATION 3:
MEDICATION 4:
MEDICATION 5:
MEDICATION 6:
MEDICATION 7:
MEDICATION 8:
MEDICATION 9:
MEDICATION 10:
Other additional medications or supplements:
Have you taken any medications in the past for fibromyalgia, other pain, depression, anxiety, or sleep problems? (Name of medication, indication, dose, start and stop date)
Drug Allergies &/or Adverse Reactions
What Medications are you allergic to or have adverse reactions
Type of reaction
Medication 1:
Medication 2:
Medication 3:
Medication 4:
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