Surf Therapeutics

What’s your full name?

Date of Birth

City, state

ZIP Code

Email Address

Phone Number

Biographical Information

Preferred Method of Contact (select one)

Phone

Text

Rheumatoid Arthritis Diagnosis

Have you been diagnosed with Rheumatoid Arthritis (RA) by a physician? (select one)

Yes

Have you been told you tested positive for RA antibodies or are “seropositive” (RF and/or anti-CCP antibodies)? (select one)

Yes

Not sure

Year of RA diagnosis (YYYY)

Do you currently experience active joint pain, swelling, or stiffness? (select one)

Yes

Inflammation & Biomarkers

Have you had a blood test for CRP within the last 6 months? (select one)

Yes

Not sure

Pregnancy Screening

Are you currently pregnant or planning to be pregnant in the next 6 months? (select one)

Yes

Not applicable