UC Prescreener Questionnaire | Xera Med Research

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Complete Our Pre-screener Questions

to See if You Qualify

All information is kept strictly confidential and HIPAA compliant.

We will contact you to let you know whether or not you qualify. If you do not qualify at this time, you can choose to be contacted again to notify you of new studies for which you may be eligible.

Are you currently taking any of the following medications? Please select all that apply.

Entvyio (vedolizumab)

Humira or Amjevita (adalimumab)

Enbrel or Ereizi (etanercept)

Remicade (infliximab)

Simponi (golimumab)

Cimzia (certolizumab pegol)

Not taking any of the above

How long ago were you diagnosed with UC?

Less than 3 months ago

3-6 months ago

6-12 months ago

More than 1 year ago

Not Sure

You are completing this form for a current Ulcerative Colitis (UC) study. Do you also have Crohn's Disease?

Have you taken any of the following medications to treat UC? Check all that apply.

Oral aminosalicylates

Oral corticosteroids

Azathioprine

Methotrexate

Not taking any of the above

If you were taking any of the above but stopped, please indicate when you stopped the treatment and describe if any of these treatments caused intolerance or were ineffective in treatment of UC

Any other information you'd like to share or questions you'd like to ask?

Thanks for submitting! We will get back to you soon to let you know if you qualify!

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