Human Energy Research Organization (HERO) 8-Week Pain & Functional Outcomes Study
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Contact Details
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Pain Qualification
Have you experienced pain or a functional limitation that would make you appropriate for an 8-week outcomes study?
*
Yes
No
Not sure
What type of pain are you experiencing? Select all that apply.
*
Chronic joint pain
Knee pain
Ligament pain
Neck pain
Shoulder pain
Tendon pain
Back pain
Sciatica or nerve-related musculoskeletal pain
Other
Primary pain condition to track during the study
Primary pain location
How long has this primary pain been present?
Less than 12 weeks
12 weeks to six months
6 to 12 months
1 to 3 years
More than three years
How stable has your pain been over the past month?
Stable/about the same
Gradually improving
Gradually worsening
Highly variable
Eligibility Screening
Are you currently using BPC-157 or TB-500
Yes
No
Have you used BPC-157 or TB-500 within the previous 60 days?
Yes
No
Are you pregnant or breast-feeding?
Yes
No
Not applicable
Do you currently have an active infection?
Yes
No
Have you had major surgery within the last 30 days?
Yes
No
Do you have surgery planned in the next eight weeks?
Yes
No
Are you currently participating in another clinical or interventional study?
Yes
No
Please list any major medical conditions, active malignancy, autoimmune disease, or other health concerns.
Medication and Treatment Stability
Have you started or changed any pain medication’s within the last 30 days?
Yes
No
Current pain medication‘s, supplements, or therapies used for pain/recovery
Are you planning any of the following during the next 8 weeks?
*
Steroid injection
Physical therapy
PRP injection
Chiropractic treatment
Surgery
New pain medication
Surgery
None planned
Baseline Prom: Pain Scores
How would you rate your average pain level over the past 7 days?
No pain
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
1 is No pain, 10 is Worst pain imaginable
Rate your worst pain level over the past seven days?
No pain
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
1 is No pain, 10 is Worst pain imaginable
Rate your best pain level over the past seven days?
No pain
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
1 is No pain, 10 is Worst pain imaginable
How would you rate your pain right now?
No pain
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
1 is No pain, 10 is Worst pain imaginable
Baseline Prom: Function and Interference
Please rate each item on a scale of 0–10, where 0 indicates no interference and 10 indicates complete interference.
Pain interference with general activity
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Pain interference with work, chores, or normal responsibilities
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Pain interference with walking or movement
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Pain interference with mood
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Pain interference with enjoyment of life
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Baseline Prom: Sleep and Quality of Life
Sleep quality over the past seven days: 0 = very poor, 10 = excellent
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Pain interference with sleep: 0 = none, 10 = severe
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Satisfaction with current pain control: 0 = very dissatisfied, 10 = very satisfied
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Study Commitment
I understand the study requires taking one BPC-157 / TB-500 oral dissolvable strip daily for eight weeks unless otherwise directed by the Provider.
I understand
I agree to complete brief weekly questionnaires and a final week 8 assessment.
I agree
I agree to report medication changes, new procedures, adverse events, or major changes in my pain treatment plan.
I agree
I understand missed questionnaires may make me ineligible for completion rewards.
I understand
I understand BPC-157 and TB-500 are investigational compounds and are not FDA-approved for the treatment of pain. Individual results may very.
I understand
Final Notes
Anything else you would like to provide Provider or study team to know?
Submit
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