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Patient Registry
Join Our Patient Registry
Step 1 / 1 : Contact Details
What’s your full name?
Date of Birth
City, state
Email Address
Phone Number
Biographical Information
Preferred Method of Contact (select one)
Phone
Email
Text
Rheumatoid Arthritis Diagnosis
Have you been diagnosed with Rheumatoid Arthritis (RA) by a physician? (select one)
Yes
No
Have you been told you tested positive for RA antibodies or are “seropositive” (RF and/or anti-CCP antibodies)? (select one)
Not sure
Year of RA diagnosis (YYYY)
Do you currently experience active joint pain, swelling, or stiffness? (select one)
Inflammation & Biomarkers
Have you had a blood test for CRP within the last 6 months? (select one)
If yes, do you recall your most recent CRP value? (select one)
< 3 mg/L
3–9 mg/L
10–14 mg/L
≥ 15 mg/L
Current & Prior RA Treatments
What Accident Happened?
Methotrexate
Leflunomide
Sulfasalazine
Hydroxychloroquine
TNF inhibitors (Humira, Enbrel, Remicade, etc.)
IL-6 inhibitors (Actemra, Kevzara)
JAK inhibitors (Xeljanz, Rinvoq, Olumiant)
Other biologic or targeted therapy (list)
None
Which medications have you tried in the past? (check all that apply)
Have you previously failed to have a response or lost response to at least one biologic or targeted synthetic DMARD? (select one)
How many biologic or targeted synthetic DMARD therapies have you previously tried? (select one)
1
2
3 or more
Are you currently taking oral corticosteroids (e.g., prednisone)? (select one)
If yes, daily dose (mg)
General Health & Medical Exclusions
What is your sex? (select one)
Male
Female
Other
What is your height? (number)
feet
inches
What is your weight? (number)
pounds
Do you have any of the following active medical conditions? (check all that apply)
Infection requiring antibiotic, antifungal, or antiviral medications
Cancer requiring chemotherapy or immunotherapy
Abdominal surgery or trauma to your abdomen within the last 30 days
Fibromyalgia or other diffuse pain syndrome
None of the above
Are you a current tobacco smoker or do you use nicotine products (patches, gum, lozenges, chewing tobacco, snuff, snus)? (select one)
Do you have a history of any of the following medical conditions? (check all that apply)
Removal of your spleen, enlarged spleen, or other spleen disorder
Vagal nerve injury or vagal nerve implant
Autonomic disorder
Pregnancy Screening
Are you currently pregnant or planning to be pregnant in the next 6 months? (select one)
Not applicable
Interest in Clinical Trials
How interested are you in a once daily at-home ultrasound treatment for RA? (select one)
Very interested
Interested
Neutral
Disinterested
Very disinterested
Do you consent to being contacted about ongoing or planned clinical trials by Surf Therapeutics?
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