Pre-Screening Questions

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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

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?