Chronic Hives Questionnaire

This clinical trial is enrolling people who have one or more of three types of Chronic Inducible Urticaria (CINDU):

  • Symptomatic dermographism (when hives are triggered by rubbing or scratching the skin, for example from clothes or jewelry) PLEASE CONSIDER THAT ENROLLMENT IN THIS TRIAL OF PEOPLE WITH SYMPTOMATIC DERMOGRAPHISM IS COMPLETE IN THE U.S.
  • Cold urticaria (when hives are triggered by cold temperatures, such as cold weather or exposure to cold water)
  • Cholinergic urticaria (when hives are triggered by an increase in body temperature or sweating, for example due to exercise or taking a hot bath)

People who are currently experiencing urticaria symptoms from unknown triggers, also called CSU (Chronic Spontaneous Urticaria), are NOT eligible for this clinical trial.

To see if you qualify, please complete the questionnaire below. Completing this online questionnaire does NOT obligate you to participate in the clinical trial.

1.Are you 18 years of age or older?

Yes

No

2.How long have you had Chronic Hives??

Chronic hives are characterized by the recurrence of itchy hives (wheals/welts) that lasts more than 6 weeks and is induced by specific physical or environmental stimuli.

0 - 2 months

3 or more months

3.Have you been diagnosed by a medical doctor with Chronic Urticaria (Chronic Hives)?

Yes

No

4.Do you know what triggers your hives?

When you are exposed to cold or a drop in temperature

When your skin is rubbed or scratched

When you start to sweat or when there is an increase in your body temperature from exercise, stress, spicy foods, or heat

No identified cause

Unsure

No hives or Urticaria

5.Do you continue to have symptoms of Chronic Urticaria (e.g., hives, itching and/or swelling) after treatment with antihistamines??

Common types of antihistamines include but are not limited to:
• Brompheniramine (Dimetane®)
• Cetirizine (Zyrtec®)
• Chlorpheniramine (Chlor-Trimeton®)
• Clemastine (Tavist®)
• Diphenhydramine (Benadryl®)
• Fexofenadine (Allegra®)
• Loratadine (Alavert®, Claritin®)
• Desloratidine
• Levocetirizine
• Rupatadine

Yes taking antihistamines, but I still have symptoms

Yes taking antihistamines, and I have no symptoms

Not taking antihistamines

Not applicable

6.Do you have any of the following conditions?

  • Active Tuberculosis
  • Heart Disease (e.g., heart attack, stroke)
  • Active Hepatitis B/Hepatitis C
  • Human Immunodeficiency Virus (HIV)
  • History of Gastrointestinal bleeding
  • Hypertension
  • Renal Disease
  • Significant bleeding risk or coagulation disorder (e.g., Hemophilia)
  • Uncontrolled asthma, Inflammatory bowel disease (IBD), or other diagnosis with flares treated by corticosteroids?

Common types of corticosteroids include:
• Hydrocortisone (Cortef®)
• Cortisone
• Ethamethasoneb (Celestone®)
• Prednisone (Prednisone Intensol™)
• Prednisolone (Orapred®, Prelone®)
• Triamcinolone (Aristospan® Intra-Articular, Aristospan® Intralesional, Kenalog®)
• Methylprednisolone (Medrol®, Depo-Medrol®, Solu-Medrol®)
• Dexamethasone (Dexamethasone Intensol™, DexPak® 10 Day, DexPak® 13 Day, DexPak® 6 Day)
• Fludrocortisone (Florinef®)

Yes

No

7.Are you pregnant? Or plan to be pregnant in the next 12 months?

Yes

No

8.What is your race? This question is completely optional: if you don’t want to answer it, select the “I don’t want to answer” option.?

Why are we asking this question? We are collecting this information in an effort to monitor if our patient recruitment materials reach a diverse audience as part of our effort to increase diverse representation in our clinical studies. Diverse, inclusive studies are critical to understanding how certain patient populations may respond to a particular treatment or medicine. They also help to identify and address unique circumstances that may arise in different patient populations while on therapy or taking a medication. Your race or ethnic group does not determine eligibility for the study.

White

Black / African American

Asian

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Other

I don’t want to answer

9.What is your ethnic group? This question is completely optional: if you don’t want to answer it, select the “I don’t want to answer” option. ?

Why are we asking this question? We are collecting this information in an effort to monitor if our patient recruitment materials reach a diverse audience as part of our effort to increase diverse representation in our clinical studies. Diverse, inclusive studies are critical to understanding how certain patient populations may respond to a particular treatment or medicine. They also help to identify and address unique circumstances that may arise in different patient populations while on therapy or taking a medication. Your race or ethnic group does not determine eligibility for the study.

Hispanic or Latino

Not Hispanic or Latino

Unknown

I don’t want to answer

10. What is your zip code?