Postherpetic Neuralgia Clinical Trial (PHN)

Welcome ~ A clinical trial to suit you could be just a few clicks away!

PHN can occur after herpes zoster infection (shingles) and is characterised by pain in the shingles-affected areas. PHN can take the form of different kinds of pain. It may present as constant pain, characterised by burning, aching or throbbing; as occasional pain, including stabbing and shooting pain; or as conditions such as allodynia (pain results from a stimulus that is normally non-painful, such as a cold breeze or a light touch from clothing).

If symptoms persist despite current treatments, you may want to consider participating in a clinical research study with an investigational study medication. By participating in a study for Postherpetic Neuralgia (PHN) you will be taking a more proactive role in your own health care and may help doctors to confirm if the study drug is effective.

Study treatments are provided at no cost to you.

Please answer a few short questions. You will be notified immediately if you meet the initial criteria for the study.

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* 1. By completing this form you agree to be added to our participant database. Please indicate below if you are happy to be contacted for future studies that have been approved by a Human Research Ethics Committee. Your privacy is important to us and your information will not be passed on to any third parties.

I agree

Do not add me to the future studies database

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* 2. Please enter your details so we can contact you about the study:

Name

Phone Number

Email Address

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* 3. Please enter your date of birth (DD/MM/YYYY)

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* 4. If you know your approximate height & weight, please enter below:

Height (cms)

Weight (Kg)

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* 5. Are you currently pregnant or planning a pregnancy?

Yes

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* 6. Are you suffering pain for at least 3 months after your shingles outbreak?

Yes

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* 7. How would you rate your average pain level in your shingle rash region over the past week?

No pain

Mild

Moderate

Severe

Extreme

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* 8. Where is your shingles pain / PHN located? (tick all that apply)

Face / Scalp

Torso / Limbs - Please add more detail if you would like to:

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* 9. Do you have any of the following? (tick all that apply)

Active Shingles / Herpes Zoster Lesions

Cancer

Dermatitis

Hepatitis B, Hepatitis C, HIV

Other Severe Chronic Pain Conditions: eg; Fibromyalgia, Rheumatoid Arthritis

None

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* 10. Please indicate your approximate travel time to Broadmeadow NSW

Less than 45 minutes

45 - 90 minutes

90 minutes - 2 hours

More than 2 hours