Screening Questionnaire
COMIRB #20-0206 -- Sputum Studies of Anti-Citrullinated Protein Antibodies (ACPA) and Rheumatoid Arthritis (RA)
Origins [SPARO] ; Kristen Demoruelle, MD, PhD
We are trying to learn more about the causes of rheumatoid arthritis (RA) . People who get RA have elevated protein markers called autoantibodies in their blood years before initial symptoms of arthritis.
In this study, we are planning to learn more about how autoantibodies in RA might be related to inflammation in the lungs.
Our current study involves coming in for a visit at the Barbara Davis Center on the UCH medical campus . During the visit, we will draw your blood , collect sputum , and administer a clinical joint exam performed by a rheumatologist. Prior to your visit, you will fill out several questionnaires that ask questions about your health history, family health history, and environmental factors.
Please complete the questions below. If you are interested in participating and qualify for our current study, you will be contacted shortly with the study consent and questionnaires.
Thank you!
Today M-D-Y
Please indicate whether you agree to complete the screening questionnaire for this study. If you decide you are no longer interested in the study as you complete the questions, simply close the screen to exit the survey.
* must provide value
Yes--I want to proceed with the questionnaire
No--I do not want to complete the screening questionnaire
If you are interested in being a research participant for one of our studies but are not interested in the current study, please provide a reason for declining participation:
Select all that apply.
Please specify what 'Other' reason has caused you to decline participation:
Female
Male
Have you had a hysterectomy?
No
Yes
Have you undergone a sterilization procedure (tubal implant, tubal ligation)?
No
Yes
Have you gone through menopause?
(Menopause typically occurs in your late 40s to early 50s. You may have completed menopause when you have gone 12 months without a menstrual period. You may currently be going through menopause, if you are experiencing irregular periods, hot flashes, vaginal dryness, sleep disturbances, and mood swings )
No
Yes
Currently going through menopause
Unsure
Male
Female
Transgender Male
Transgender Female
Gender Variant (non-conforming)
Prefer Not to Say
Other
Please specify 'Other' gender identity
Date of birth:
Note : If the next question does not appear after entering your dob, click out of the dob field (anywhere on this screen), or hit tab on your keyboard.
* must provide value
M-D-Y MM/DD/YYYY
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Have you ever been diagnosed with an autoimmune disease?
No
Yes
What autoimmune disease(s) have you been diagnosed with?
Do you have a family member who's been diagnosed with Rheumatoid Arthritis?
No
Yes
Is the family member either your parent, sibling, or child (first-degree relative)?
No
Yes
If diagnosed with RA:
if enrollment has restarted for this group in SPARO, you can enroll them. Otherwise we can recruit into MINERAL or PEARL. (5/1/23)
If not diagnosed with RA:
If their relative is not first-degree, check their medications. If they are taking immunosuppressants, they would not qualify for any of our studies. If no immunosuppressants, they can be recruited for RA-SCREEN instead. We only want confirmed FDRs for SPARO.
Has your family member taken any medications to treat Rheumatoid Arthritis or to relieve pain associated with Rheumatoid Arthritis?
No
Yes
Please mark which medications your family member with Rheumatoid Arthritis has taken (currently or in the past).
Aspirin (Anacin, Bufferin, Ecotrin, Bayer, Alka-Seltzer, etc.)
Azathioprine (Imuran)
Cyclophosphamide (Cytoxan)
Cyclosporine (Sandimmune or Neoral)
Dapsone
Excedrin
Gold pills (Ridaura)
Gold shots (Myochrysine or Solganol)
Hydroxychloroquine (Plaquenil)
Leflunomide (Arava)
Methotrexate (Rheumatrex)
Minocycline
Mycophenolate Mofetil (CellCept)
Naproxen (Naprosyn, Aleve)
Penicillamine (Cuprimine or Depen)
Prednisone
Sulfasalazine (Azulfidine)
Tacrolimus (Prograf, Protopic)
Ibuprofen (Advil, Motrin)
Don't Know
Not sure, but it was an IV infusion
Not sure, but it was an injection under the skin every week or two
Other
Other Anti-Rheumatic Drug
Did your family member have a lung disease that they were told was due to their Rheumatoid Arthritis?
No
Yes
Unsure
Would your relative with Rheumatoid Arthritis be willing to complete this screening questionnaire?
No
Yes
Please provide their contact info, so a member of the research team can reach out to them.
Are you on any prescriptions?
No
Yes
Please list all prescriptions that you are currently taking.
name of medication only
Are you currently pregnant?
No
Yes
How far along are you in your pregnancy?
(Please round up/down to the nearest month .)
Do you have plans to become pregnant in the next 2 months?
No
Yes
Have you been diagnosed with a lung disease?
No
Yes
What is the lung disease with which you were diagnosed?
Do you currently require supplemental oxygen?
No
Yes
What is your oxygen requirement?
2 liters or less at rest
more than 2 liters at rest
Do you have any mobility limitations? (eg. require a wheelchair or walker)
Yes
No
Have you taken any antibiotics in the last 3 months?
No
Yes
Date you took the last dose of antibiotics:
Note : If the next question does not appear after entering the date, click out of the field (anywhere on this screen), or hit tab on your keyboard.
Today M-D-Y MM/DD/YYYY
Days since last antibiotic dose
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WARNING! Looks like the date you entered for the last dose of antibiotics is more than 3 months in the past--please revise the answer to the question on your antibiotic use or change the date of your last antibiotic dose, as appropriate.
Have you ever been diagnosed with any form of cancer?
* must provide value
Yes
No
Are you currently undergoing any form of treatment for your cancer?
* must provide value
Yes
No
If no, please enter the year when your cancer treatment concluded.
* must provide value
(yyyy)
Have you received the SARS-CoV-2 vaccine?
* must provide value
No
Yes
Are you currently on an active waitlist or scheduled to receive the SARS-CoV-2 vaccine?
* must provide value
No
Yes
Actual or expected date to get the SARS-CoV-2 vaccine
* must provide value
Today M-D-Y Can approximate, as needed.
How many doses of the vaccine have you had?
* must provide value
1 Dose
2 Doses
More than 2 Doses
Date of the most recent dose:
* must provide value
Today M-D-Y
When is your second dose scheduled?
Today M-D-Y
Have you been diagnosed with COVID-19 in the past month?
* must provide value
No
Yes
Have you had a new cough or other new-onset respiratory symptoms in the last 14 days?
* must provide value
No
Yes
Have you had a new fever in the last 14 days?
* must provide value
No
Yes
To your knowledge, have you been exposed to anyone who has been diagnosed with COVID-19 in the last 14 days?
* must provide value
No
Yes
Have you traveled to any known hotspots of COVID-19 in the past 30 days?
* must provide value
No
Yes
Where did you travel in the past 30 days?
Have you used any forms of mass transit in the past 14 days? (this includes airplanes, buses, trains )
No
Yes
What forms of mass transit have you used in the past 14 days? (select all that apply )
When did you last use any form of mass transit?
Today M-D-Y Use format MM/DD/YYYY
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What frequency of visits would you consider? (check all that apply )
* must provide value
Check all that apply .
Thank you for your interest in our studies and for participating in our quick survey. You do not qualify for the current study, but if you are interested in being contacted with potential other research opportunities in our department, please check the box and proceed by providing your contact information.
Kristen Demoruelle
with the SPARO study
Thank you for your interest in our studies and for participating in our quick survey. You do not qualify for the current study, and we do not currently have any research opportunities available for you in our department.
Kristen Demoruelle
with the SPARO study
Thank you for participating in our quick survey. We are sorry to hear that you are not interested in the current study, but if you would like to be contacted with other potential research opportunities in our department, please check this box and proceed by providing your contact information.
Kristen Demoruelle
with the SPARO study
Thank you for your interest in our studies and for participating in our quick survey. One of our study staff will reach out to you after your child has been born to reassess your interest and availability for our study. Please check the box and proceed by providing your contact information.
Kristen Demoruelle
with the SPARO study
Thank you for your interest in our studies and for participating in our quick survey. One of our study staff will reach out to you about 3 months after your last dose of antibiotics to reassess your interest and availability for our study. Please check the box and proceed by providing your contact information.
Kristen Demoruelle
with the SPARO study
Thank you for completing this questionnaire. It looks like you qualify for our current study. Please check the box to confirm your willingness to be contacted by one of our study staff with the consent and initial study questionnaires, and proceed by providing your contact information below. Please note that it can take between 1-4 weeks for study staff to contact you with the next steps for this study.
Kristen Demoruelle
with the SPARO study
Thank you for completing this questionnaire. It looks like you qualify for our current study but have had either recent symptoms / diagnosis of, or exposure to COVID-19. Based on the information provided, we will decide when / if we are able to proceed with study enrollment for you. Please check the box to confirm your willingness to be contacted by one of our study staff and proceed by providing your contact information below.
Kristen Demoruelle
with the SPARO study
Generally speaking, what is your availability? (check all that apply )
Do you have any preferences or comments regarding your availability indicated above (for example, if you selected afternoons, let us know if you are only available for parts of the afternoon or before/after a certain time)?
Where did you hear about this research opportunity?
WARNING! Please make sure we have at least your name AND email or phone number (preferably both), so we can reach you.
Please hit the submit button, and we will be in touch.
Kristen Demoruelle
with the SPARO study
Submit
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