The code block below illustrates how one might use # and // as comments in your logic and calculations.

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This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

QdDVXBk4WTfqEbGUFvh8fu5iZy8S7he2fXf4m8kHq

Atopic Dermatitis (Eczema) Survey

Thank you for choosing to participate in this survey. Please read the following instructions carefully.

Purpose: The goal of this questionnaire is to provide our research team with a brief history of your eczema condition as well as your contact information so we can reach out to provide more information on our current and upcoming clinical trials. By completing this survey you are not obligated to participate in any our clinical trials.

This survey contains questions regarding your eczema history. There are no risks associated with participation. There will be no remuneration for completing this survey. We anticipate the survey will take approximately 10-15 minutes to complete.

If you are interested in enrolling an for eczema study, please enter the information below. Our Stanford research staff members will contact you directly within the next few days to tell you more about the study, and answer any questions you might have. By speaking with us, you are not under any obligation to enroll in the study.

First name

* must provide value

Last name

* must provide value

Younger than 18

18-29

30-39

40-49

50-64

65 and older

Age

* must provide value

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Male

Female

Other

Gender

* must provide value

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Address (Street address, City, State, Zip code)

* must provide value

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Phone number (eg: Home, Mobile, Work)

* must provide value

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* must provide value

Preferred method of contact

* must provide value

Phone

Both

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Best time to contact

* must provide value

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Have you been diagnosed with atopic dermatitis/eczema by a physician/health care provider?

* must provide value

Yes

Not sure

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At what age did you start to have eczema?

* must provide value

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Eczema concentrated in just one small area

Eczema in a few areas

Is your eczema concentrated in just one small area on your body, or in a few areas on your body?

* must provide value

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Please indicate the body areas affected by eczema (select all that apply)

* must provide value

Face

Scalp

Neck

Arms

Hands

Underarms

Elbows

Knees

Flexures of arms (elbow pits) or legs (knee pits)

stomach area, or back (trunk)

Groin

Legs

Feet

Less than 3 palms

Between 3 to 5 palms

Between 5 to 7 palms

Between 7 to 10 palms

Between 10 to 15 palms

Not sure

If you were to place just your palm over all of the eczema you have, about how many palms would it take to cover up ALL of the eczema on your body

* must provide value

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Yes

Not sure

Within the past 4 weeks, have you used any immunosuppressive medications by mouth orinjection for your eczema, or any other medical condition? Examples would include corticosteroids by mouth or injection (like Prednisone, Medrol, Methylprednisolone, or steroid shot), cyclosporine, methotrexate, etc.

* must provide value

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Within the past 4 weeks, have you undergone phototherapy, also called light therapy, for your eczema?

* must provide value

Yes

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Please provide other treatments you have received for eczema (if applicable)

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Are you or your partner pregnant, breastfeeding, or planning a pregnancy in the next 9 months?

* must provide value

Yes

Not applicable

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Have you been involved in any other clinical studies that involve an investigational medication in the past 3 months?

* must provide value

Yes

Not sure

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Name of clinical studies:

* must provide value

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Would you like us to contact you about future studies that may be of your interest?

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.