BCFS0069-StonyBrook-Moeller-Smoking [Screening Form] -

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?

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

Have you been experiencing knee pain on and off for at least 6 months?

Yes

Are you open to using a mobile device, such as a smartphone or tablet, throughout the entire duration of the study? If you do not have one, a loaner device will be provided.

Yes

Please rate your current level of knee pain using the options below.

No pain

Mild pain

Moderate pain

Severe pain

Extremely severe pain

BMI question

Standard

Height

Weight

If female, are you currently pregnant or breastfeeding?

Yes

N/A - Male

Are you willing to refrain from illicit drug use during the study? Note: Medical marijuana is allowed depending on if it is legal in your state.

Yes

Have you had knee surgery within the past 12 months?

Yes

N/A- I do not have knee pain

Do you experience any painful conditions in the afflicted knee aside from osteoarthritis?

Yes

N/A- I do not have knee pain

Are you planning to have surgery, invasive procedures, or intra-articular (IA) injections of the afflicted knee in the next year?

Yes

Have you received a corticosteroid injection in the afflicted knee within the past 30 days?

Yes

Do you have any history of cancer in the last 5 years?

Yes

Have you been diagnosed by a doctor with any of the following medical conditions: Inflammatory bowel disease (IBD) Severe GERD Seizures Diabetes Myofascial pain syndrome Fibromyalgia Hematologic pain Neuropathic arthropathy Cancer Cardiovascular disease Congestive heart failure Rheumatoid Arthritis COPD Multiple Scerosis Hepatitis Cirrhosis Crohn’s Disease Celiac Disease HIV/AIDS

Yes

Are you currently taking any of the following medications and are willing to stop for the duration of the study: â€¢Advil, Motrin, Ibuprofen, Naproxen, Aleve, Amiodarone, Warfarin, Coumadin, Lamotrigine, Carbamazepine, Ketoconazole, Itraconzole, Diltiazem, Verapamil, Indomethacin, Itraconazole, Triptans, Scopolamine, Varenicline, Chantix, Metoclopramide, Omeprazole, Pantoprazole, St. Johnâ€™s Wort, Niacin, Niacinamide, Insulin

Yes – I am taking these medications and am willing to stop for duration of study

No - I am not taking any of these medications

I am taking these medications and will not be able to stop for the study

Not Sure- I would need to discuss with the study team

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