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Screening Form
Please complete the screening form below
First Name
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Last Name
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Phone Number
Email Address
Gender
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Male
Female
Date of Birth
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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
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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
What category best describes your child?
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 child’s name?
What is your child’s age?
Has your child experienced atopic dermatitis (eczema) that has persisted for at least one year in his/her medical history?
Yes
No
Could you/your child agree to abstain from applying topical steroids to the designated area for a specified duration as part of the study?
Yes
No
N/A
Is your child currently using dupilumab (Dupixent) as a treatment for his/her atopic dermatitis?
Yes
No
N/A
Does your child 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 your child:
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 child’s 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
Has your child needed to use systemic corticosteroids as treatment for his/her asthma within the last three months?
Yes
No
Has your child had a significant history of heavy alcohol or drug use within the past two years?
Yes
No
Does your child have a planned major surgical procedure in the next 6 months?
Yes
No
In the past month, has your child 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
Is your child currently pregnant, breastfeeding, or planning to become pregnant in the next 6 months?
Yes
No
N/A
Is your child currently involved in an investigational trial or using an investigational drug?
Yes
No
Are you and your child 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.
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BCFS00599
