Skip to content
Screening Form
Please complete the screening form below
Displayed
First Name
Displayed
Last Name
Phone Number
Email Address
Hidden
Gender
Male
Female
Hidden
Date of Birth
What city do you live in?
What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Select
What category best describes you?
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
What is your age?
Have you experienced atopic dermatitis (eczema) that has persisted for at least one year in your medical history?
Yes
No
Could you agree to abstain from applying topical steroids to the designated area for a specified duration as part of the study?
Yes
No
N/A
Are you currently using dupilumab (Dupixent) as a treatment for your atopic dermatitis?
Yes
No
N/A
Do you have a known hypersensitivity to Vanicream (TM), hydrocortisone, triamcinolone, or dupilumab?
Yes
No
Please select any of the following skin diseases (other than atopic dermatitis) that apply to you:
Bullous disease
Psoriasis
Cutaneous T cell lymphoma (also called Mycosis Fungoides or Sezary syndrome)
Dermatitis herpetiformis
Hailey-Hailey
Darier’s disease
None of the above
Please select any of the following situations that apply to your medical history:
Non-malignant lymphoproliferative disorder
Parasitic infection
Cancer within the last 5 years
Keloid formation
Life-threatening reaction to tape or adhesives
Asthma
Invasive opportunistic infections (e.g., tuberculosis, histoplasmosis)
Compromised/weakened immune system
HIV
None of the above
Have you needed to use systemic corticosteroids as treatment for your asthma within the last three months?
Yes
No
Have you had a significant history of heavy alcohol or drug use within the past two years?
Yes
No
Do you have a planned major surgical procedure in the next 6 months?
Yes
No
In the past month, have you experienced any chronic or acute infections (e.g., pneumonia, UTI, bronchitis, STIs, fungal skin infections) that required treatment with medications such as systemic antibiotics, antivirals, antiparasitics, antiprotozoals, or antifungals?
Yes
No
Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 6 months?
Yes
No
N/A
Are you capable of becoming pregnant (females only)?
Yes
No
N/A
If you are sexually active, would you be willing to utilize FDA-approved methods of birth control (such as hormonal contraceptives, intrauterine devices, double barrier contraception, or a male partner with a documented vasectomy) throughout the duration of the study?
Yes
No
N/A
Are you currently involved in an investigational trial or using an investigational drug?
Yes
No
Are you willing to adhere to a study protocol that involves applying a consistent dose of a provided topical moisturizer (specifically, Vanicream) at least twice daily to a designated area of the skin for a specific duration of the study?
Yes
No
You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.
Displayed
Captcha
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00599
