Back Pain / Ankylosing Spondylitis (AS) Questionnaire

Thank you for your interest in learning more about our clinical research opportunities. See if you may qualify by answering a few short questions. By filling out the interest form below, you consent to being contacted by our patient enrollment specialists via phone, text, or email with more information.

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Camp ID

First Name

Last Name

Select Gender

Gender

Date of Birth

Date

Language

Current Date

Date

Age

Primary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Secondary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Email

example@example.com

Metro Area

Zip Code

Metro Code

SiteId

State ID

CampRefID

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Have you been diagnosed with ankylosing spondylitis (AS) or axial spondyloarthritis (axSpA) for at least 6 months?

Are you currently having ongoing back pain or stiffness?

In the past 4 weeks, have you taken or received any of the following treatments?

Have any of these treatments not worked well for you?

Have you been diagnosed with any of the following conditions?

Do you currently have, or have you recently had, any of the following?

Eligibility Status