Pre-Screening Questions

Your information will not be sold or shared with third parties for their own separate use.
What is your date of birth?  
Month Day Year
Please enter your height and weight so we can estimate your BMI:
Height (feet, inches) ft. in.
Weight (lbs.)
What is your gender?

Do you believe you have any one of the following or have a doctors’ diagnosis of any of the following:
  • Chronic idiopathic urticaria (CIU)
  • Chronic idiopathic pruritus (CIP)
  • Lichen planus (LP)
  • Lichen simplex chronicus (LSC)
  • Plaque psoriasis (PPs)






Have you used any of the following antihistamines to treat your chronic pruritus (itch), but still experience the symptoms?
  • Allegra
  • Allergia-C
  • Alavert
  • Benadryl
  • Claritin
  • Tavist
  • Unisom
  • Zyrtec



Are you currently experiencing an itch flare up?

If you think back on the itching over the last 2 weeks, how would you rank the severity of your itchiness?










Do you have any of the following skin conditions?
  • Pustular psoriasis
  • Erythrodermic/exfoliative psoriasis
  • Drug-induced psoriasis
  • Atopic dermatitis

Do you have any of the following diseases?
  • Psoriatic arthritis
  • Uncontrolled hyperthyroidism or hypothyroidism
  • Insulin-dependent diabetes
  • Uncontrolled diabetes
  • Rheumatoid arthritis, lupus, inflammatory bowel disease (IBD), multiple sclerosis (MS)
  • Hepatitis C
  • HIV/AIDS

Have you ever had a severe allergic reaction to any food or medications?

Have you had cancer or a lymphoproliferative disease in the past 5 years?

Have you taken Dupilumab (Dupixent) in the last 5 months?

Have you been hospitalized or had a major surgery in the last 2 months?