CHRONIC HIVES (CSU) RESEARCH STUDY

Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1980)

City and State

Do you consent to being contacted about this study and future research opportunities?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Have you been diagnosed with chronic spontaneous urticaria (CSU) — also known as chronic hives — by a physician?

Yes No

Are your hives caused by any known or identifiable trigger (such as cold, heat, pressure, certain foods, medications, or another specific trigger)?

Yes No Unsure

Do you experience flares of moderate to severe hives and itch (bad enough to be clearly bothersome) about 1–2 times a month or every other month, and has this been consistent over the past year while on your regular treatment?

Yes No Unsure

Have you been receiving treatment for your chronic spontaneous urticaria for at least the past 6 weeks (for example, antihistamines, Xolair®, or another prescribed treatment)?

Yes No Unsure

Are you willing and able to use a smartphone app to record study assessments and take photographs of your symptoms?

Yes No

Have you been diagnosed with significant hypertension (high blood pressure) or cardiovascular disease within the past 10 years?

Yes No Unsure

Have you been diagnosed with any of the following significant medical conditions?

Please select all that apply.

Have you experienced any major injury (trauma) or undergone major surgery within the past 30 days?

Yes No Unsure

Do you have a known allergy to epinephrine (adrenaline) or any closely related medication?

Yes No Unsure

Do you currently take any of the following: a beta-blocker, a monoamine oxidase inhibitor (MAOI), or a COMT inhibitor?

Yes No Unsure

Beta-blocker examples: metoprolol, atenolol, propranolol, carvedilol, bisoprolol, nebivolol.

Please list your current medications so the study team can check.

Have you taken part in a clinical trial involving an investigational drug or treatment within the past 30 days?

Yes No Unsure

Taking part in an observational (non-interventional) study is fine.

If you are able to become pregnant, are you currently pregnant or breastfeeding?

Yes No Not applicable

If you are eligible, would you be willing and able to attend all required study visits and follow the study procedures?

Yes No

CHRONIC HIVES (CSU) RESEARCH STUDY — Pre-Screening