Pre-Screener

Chronic Hives Questionnaire

Thank you for your interest in a clinical trial for chronic hives, also known as chronic urticaria.

To see if you might qualify for a clinical trial and to be referred to the local trial center in your area, please take a moment to complete the questionnaire below. Answering all questions should take about 2 minutes. This questionnaire is for recruitment of adult patients only (18+). If you want to know more about a chronic induced urticaria clinical trial for adolescents, click here.

There’s no obligation

Completing the online questionnaire does NOT obligate you to participate in one of three Chronic Urticaria Clinical Trials. You will be asked questions about your health and medical history, and other questions that will help to determine if you may qualify to participate in a Chronic Urticaria Clinical Trial. If you grant permission, and your health history is a match for trial requirements, you will be contacted by a member of the Clinical Study Team at the clinic. The Clinical Study Team may contact you by telephone, email or text.


1. How old are you?

Younger than 17

18 or older

2. How long have you had Chronic Hives?

0-1 Months

2-4 Months

4-6 Months

6+ 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? Mark all that apply:

When you are exposed to cold

When your skin is scratched

When there is a change in your body temperature

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 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 they are not controlling my urticaria symptoms

Yes taking antihistamines, and they are controlling my urticaria symptoms

Not taking antihistamines

Not Applicable

6. Are you pregnant? Or, plan to be pregnant in next 16 months?

Yes

No / Not Applicable

7. Do you have any of the following conditions? Mark all that apply:

Heart Disease (e.g. heart attack, stroke)

Cancer

Active Tuberculosis

HIV

Hepatitis B-C

History of alcohol or drug abuse

Diabetes or Hypercholesterolemia

Planned Surgery

None of the above

8. What is your zip code?