DoLPHin Study – Primary Sclerosing Cholangitis (PSC) Research Study Screener

Full Name

Email Address

Phone Number

Date of Birth

City and State

May we contact you about future studies?

Yes No

What types of studies would you be interested in?

Have you been diagnosed with Primary Sclerosing Cholangitis (PSC) for at least 6 months, confirmed by ERCP or MRCP imaging?

Yes No

Are your alkaline phosphatase (ALP) levels currently more than 1.5 times the upper limit of normal?

Yes No Unknown

Are you currently taking ursodeoxycholic acid (UDCA)?

Yes No

Have you been on a stable dose for more than 6 months?

Yes No

Has it been more than 4 weeks since you last took UDCA? (If you have never taken UDCA, select Yes.)

Yes No

Do you anticipate needing a liver transplant within the next 12 months, or have you had a liver transplant in the past?

Yes No

Have you experienced any of the following?
○ Variceal bleeding
○ Ascites
○ Hepatic encephalopathy

Yes No

Do you know if any of the following have been identified in your recent lab tests or by your doctor?
○ MELD score above 10
○ Bilirubin higher than 3.0
○ Platelet count below 100,000
○ INR above 1.4

Yes No Unsure

Have you been diagnosed with any of the following?
○ Alcohol-related liver disease
○ Chronic hepatitis B or C
○ Hemochromatosis
○ Wilson's disease
○ Alpha-1 antitrypsin deficiency
○ Non-alcoholic steatohepatitis (NASH)
○ Autoimmune hepatitis
○ Primary biliary cholangitis

Yes No

Have you had any confirmed malignancy within the past 5 years (excluding non-melanoma skin cancers)?

Yes No

Have you taken any investigational agents within the last 2 months or 5 half-lives (whichever is longer)?

Yes No

Do you currently use illicit drugs or consume more than moderate amounts of alcohol?

Yes No

Have you had bacterial cholangitis in the past 6 months?

Yes No

Do you have chronic kidney disease (eGFR < 60)?

Yes No

Are you currently pregnant or breastfeeding?

Yes No

Do you have uncontrolled high blood pressure (systolic above 140 or diastolic above 90)?

Yes No

Are you currently taking either of the following?
○ Vitamin C
○ Prednisone

Yes No

Would you be able to safely stop taking these before the study begins?

Yes No

Do you have a history of any of the following?
○ Arrhythmia
○ Long QT syndrome
○ Congestive heart failure
○ Stroke
○ Coronary artery disease

Yes No

Do you have any congenital or acquired immune deficiencies?

Yes No

Do you have any of the following?
○ Diabetes mellitus
○ Systemic lupus erythematosus

Yes No

Have you had an episode of acute cholangitis within the past 4 weeks?

Yes No