Plaque Psoriasis Survey

Therapeutics Clinical Research is conducting a clinical research study for an investigational oral tablet for people living with plaque psoriasis. In order to determine if you pre-qualify for this study, we will ask you a few questions about your condition. You may stop answering at any time and you do not need to answer any questions that make you feel uncomfortable.

All information you provide will be kept strictly confidential and will not be shared without your permission, except as required by law. Please feel free to call us for more information at (858) 571-6800.

By providing your contact information, you agree to receive phone calls, emails and/or texts from Therapeutics Clinical Research.

1.Tell us about yourself:(Required.)

Name:

Email Address:

Phone Number:

2.Are you between 18 and 75 years old?

Yes

3.If female, are you pregnant, nursing, or planning to be pregnant?

Yes

N/A; I am male

4.Have you been diagnosed with plaque psoriasis?

Yes

Not Sure

5.One of the primary qualifications for the study is that you have a certain percentage of your body affected with plaque psoriasis. The way you can tell what your percentage might be is: 1% is equal to about the size of your open hand including the palms and fingers. If you were to use your hand to cover up all of the psoriasis patches on your body, how many hands do you think it would take?

0% - 4%

5% - 9%

10% +

6.Are you otherwise in good general health with no major medical conditions?

Yes

No (please list medical conditions):

8.Would you like to be added to our email list to be the first to hear about new studies?

Yes

Not at this time

Thank you for completing the survey. We will review your information and contact you soon if you pre-qualify. Call (858) 571-6800 for further information.

9025 Balboa Avenue Suite 105

San Diego, CA 92123

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