Skin Health Study Pre-Screen

Skin Health Study Pre-Screen

Please complete this confidential pre-screening to determine your eligibility for our clinical research study on skin health. Your responses are secure and will only be used for study purposes.
About You
What is your age?*

Under 18 (may not qualify)18–2930–4445–60Over 60
Demographics

The following questions help support inclusive representation in clinical research.
What is your race? (Select all that apply)

WhiteBlack or African AmericanAsianNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderPrefer not to answerOther (please specify):
Are you of Hispanic or Latino/a ethnicity?

YesNoPrefer not to answer
Your Skin Profile
Which best describes how your skin reacts to sun exposure?*

Type I – Very fair skin, always burns, never tansType II – Fair skin, usually burns, tans minimallyType III – Medium skin, sometimes burns, gradually tansType IV – Olive or light brown skin, rarely burns, tans easilyType V – Brown skin, very rarely burns, tans very easilyType VI – Dark brown or deeply pigmented skin, never burnsNot sure
Your Skin Experience
Which of the following best describes your current skin concerns? (Select all that apply)*

Persistent dryness or rough textureRedness or visible irritationSensitive or easily reactive skinFrequent itching or discomfortSkin that cracks, flakes, or peelsNone of the above
How often do you experience these skin concerns?*

Occasionally (comes and goes)Frequently (several days per week)Most of the time (ongoing or persistent)
How would you rate the overall severity of your skin concerns?*

Mild (noticeable but not bothersome)Moderate (bothersome and affects daily comfort)Severe (significantly impacts comfort or daily activities)Not sure
Which of the following are you currently experiencing? (Select all that apply)*

ItchingRednessDry or flaky skinCracking or scalingBurning, stinging, or irritationSkin discomfort that interferes with sleepSkin discomfort that affects daily activities
Current Skincare Use
Are you currently using any products for your skin concerns?*

Over-the-counter creams or moisturizersPrescription topical productsInjectable or advanced skincare treatmentsNone
Have you used prescription or advanced skincare treatments in the past 6 months?*

YesNoNot sure
Study Participation
Are you able to attend clinic visits in Chicago?*

YesNo
Additional Skin History

This helps us better understand your skin profile.
Have you been evaluated by a healthcare provider for ongoing dry, irritated, or sensitive skin within the past 12 months?*

YesNoNot sure
Reproductive Health

The following questions are required for safety and eligibility in clinical research.
Sex assigned at birth:*

FemaleMaleIntersexPrefer not to answer
Are you a woman of childbearing potential?*

YesNoNot sure
Are you currently pregnant or breastfeeding?*

YesNoNot sure
Are you currently experiencing menstrual bleeding?*

YesNoNot applicable
Are you postmenopausal (no menstrual period for 12+ months)?*

YesNoNot sure
Upload Images of Problem Areas

Cancelof
Contact Information
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Privacy & Authorization (HIPAA Notice)
Your privacy is important to us. The information you provide will be used solely to determine your eligibility for participation in this clinical research study.
- Your responses may include protected health information (PHI).
- This information will be securely stored and accessed only by authorized study personnel.
- Your information will not be sold or shared outside the research team without your permission, except as required by law or regulatory authorities (e.g., FDA, IRB).
- Completing this form does not obligate you to participate in the study.
Consent to Be Contacted
Signature*
Date*

MonthDayYear
Date
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Skin Health Study Pre-Screen

About You

Demographics

Your Skin Profile

Your Skin Experience

Current Skincare Use

Study Participation

Additional Skin History

Reproductive Health

Contact Information

Consent to Be Contacted