COMIRB #14-1751 -- Female Influences on the Etiology of Rheumatoid Arthritis [FIERA]; Kristen Demoruelle, MD, PhD
We are currently looking to understand why women get RA more often than men. Our current study involves coming in for a visit at the Barbara Davis Center on the UCHealth medical campus.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.
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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:
Sex at Birth
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Female Male
What is your gender?
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Male
Female
Transgender Male
Transgender Female
Gender Variant (non-conforming)
Prefer Not to Say
Other
Date of birth:
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Today M-D-Y Format: MM/DD/YYYY
View equation Have you had a hysterectomy?
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No
Yes
Have you undergone a sterilization procedure (tubal implant, tubal ligation)?
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No
Yes
Have you gone through menopause?
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No
Yes
Currently going through menopause
Unsure
Please specify 'Other' gender identity
Do you currently have regular menstrual periods?
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No
Yes
Do you have any menstrual periods?
* must provide value
No
Yes
When did your last menstrual period start?
Today M-D-Y
Notes regarding irregular menstrual periods (eg, timeline, spacing between)
Have you ever been diagnosed with an autoimmune disease?
* must provide value
No
Yes
What autoimmune disease(s) have you been diagnosed with?
Do you have a family member who's been diagnosed with Rheumatoid Arthritis?
* must provide value
No
Yes
Is the family member either your parent, sibling, or child (first-degree relative)?
* must provide value
No
Yes
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
Days since last antibiotic dose
View equation Are you currently pregnant?
* must provide value
No
Yes
How far along are you in your pregnancy?
Please round up/down to the nearest month.
Have you had a baby in the last 12 months?
* must provide value
No
Yes
Have you had a baby in the last 18 months?
* must provide value
No
Yes
Do you plan on becoming pregnant in the next 2 months?
* must provide value
No
Yes
Do you currently have abnormal vaginal discharge, a urinary tract infection, or an active genital infection?
* must provide value
No Yes
Would you be willing to avoid the following activities for the 3 days before your sample collection day: sexual intercourse of any kind, douching, internal vaginal washing, use of tampons, and use of vaginally applied medications or feminine sprays?
* must provide value
No Yes
Do you have a refrigerator & freezer and would be willing to keep your samples in there temporarily until your study visit? You would be given a special tube and bag for storage.
* must provide value
No Yes
Are you currently using birth control?
* must provide value
No Yes
What type(s) are you currently using?
* must provide value
Please add any "Other" contraceptive methods you regularly use:
Have you been diagnosed with a lung disease?
* must provide value
No
Yes
What is the lung disease with which you were diagnosed?
Do you currently require supplemental oxygen?
* must provide value
No
Yes
What is your oxygen requirement?
2 liters or less at rest
more than 2 liters at rest
Have you taken any antibiotics in the last 3 months?
* must provide value
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.
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Today M-D-Y MM/DD/YYYY
WARNING!
Have you received the SARS-CoV-2 vaccine?
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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
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Today M-D-Y Can approximate, as needed.
How many doses of the vaccine have you had?
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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 )
* must provide value
When did you last use any form of mass transit?
Today M-D-Y Use format MM/DD/YYYY
View equation View equation 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.
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.
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.
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 FIERA 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 FIERA 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.
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.
Email address:
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Phone number:
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Generally speaking, what is your availability? (check all that apply )
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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.
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Thank you for your participation, we currently do not have any studies available for you. Are you interested in participating in one of our research studies following the birth of your child?
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Yes
Thank you for participating in our survey, one of our study staff will reach out to you after your child has been born to reassess your interest and availability for one of our studies. Please provide us with a good phone number and/or email below.
Thank you for your participation, we currently do not have any studies available for you. Are you interested in participating in one of our research studies in the future?
No
Yes
Thank you for participating in our survey, one of our study staff will reach out to you in a few weeks to reassess your interest and availability for one of our studies. Please provide us with a good phone number and/or email below.
Where did you hear about this research opportunity?
Arthritis Foundation Flyer Posted On Campus Email (campus email list) Community Campus Partnership (CCP) Site Center for Women Health Research (CWHR) Site CO Arthritis Associates Clinic (Denver Area) Flyer Posted in Other Clinic Flyer Posted in Community Flyer/Handout from Medical Provider Other
Please tell us where you found out about this opportunity.
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Provide clinic name where flyer was provided to you
Thank you for taking the time to answer these questions.
Thank you for your interest in our studies and for participating in our quick survey. We currently do not have any studies available for you.
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