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Clinical Trials Interest Form
Thank you for your interest in being match with a Rune Labs partner for Parkinson's Disease clinical trials. We will use the information you provide to us to find you the best match.
21
Questions
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1
Patient ID
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2
Who is filling out this survey?
*
This field is required.
I am the person or caregiver
I am an APP or Provider
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3
Do you have a diagnosis of
Parkinson's Disease
?
YES
NO
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4
APP Name
*
This field is required.
First Name
Last Name
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5
Patient Name
*
This field is required.
First Name
Last Name
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6
Please enter your
email
*
This field is required.
example@example.com
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7
Please enter your
phone number
*
This field is required.
We will use this number to contact you with information about the clinical trials.
Please enter a valid phone number.
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8
Are you comfortable receiving
text messages
related to clinical trials at this number?
YES
NO
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9
Are you comfortable receiving
voicemails related to clinical trials
at this number?
YES
NO
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10
Please enter your
current address
*
This field is required.
This information helps us match you with trials that are accessible to you..
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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11
What is your
date of birth
?
*
This field is required.
/
Date
Month
Day
Year
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12
What type of
cellphone
do you use
day-to-day
?
*
This field is required.
Apple iPhone
Android (eg. Google Pixel, Samsung, etc.)
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13
How long ago were you
diagnosed
with Parkinson's Disease?
Less than 1 year ago
1 to less than 2 years ago
2 to less than 5 years ago
More than 5 years ago
Not sure
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14
How much daily
OFF time
do you experience on
average
?
OFF: Time when medication is not providing benefit with regard to mobility, slowness, and stiffness
Less than 3 hours
Greater than 3 hours
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15
Are you taking
immediate release
or
extended release Levodopa
(L-Dopa) such as: Sinemet, Stalevo, Rytary, or Crexont?
*
This field is required.
YES
NO
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16
How many times a day are you taking
immediate release Levodopa
(L-Dopa) such as: Sinemet or Stalevo?
*
This field is required.
1
2
3
4+
I am on extended release such as: Rytary or Crexont
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17
How many times a day are you taking
extended release Levodopa
(L-Dopa) such as: Rytary or Crexont?
*
This field is required.
1
2
3+
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18
Do your
symptoms return
before your next dose of
medication
? This is sometimes called "
OFF time
"
*
This field is required.
OFF: Time when medication is not providing benefit with regard to mobility, slowness, and stiffness
YES
NO
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19
On Average, how long do you
experience symptoms
before you
next dose of medication
?
*
This field is required.
OFF: Time when medication is not providing benefit with regard to mobility, slowness, and stiffness
15 Minutes
30 Minutes
1 Hour
1.5 Hours
2 Hours
2.5 Hours
3 Hours or more
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20
Do you use a
Levodopa Pump
or have a
Deep Brain Stimulation (DBS) device
?
*
This field is required.
YES
NO
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21
Are you taking one of the following meds:
Ativan
(lorazepam),
Norvasc
(amlodipine),
Metformin
(glucophage),
Crestor
(rosuvastatin),
Nexium
(omeprazole),
Ritalin
(methyphenidate)?
*
This field is required.
YES
NO
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22
Would you be willing to participate in
genetic screening
for
research purposes
?
*
This field is required.
Please note informed consent would be collected formally prior to any research activities
Yes
No
I would be willing to learn more
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23
Would you be willing to take a
study drug
for
research purposes
?
*
This field is required.
Please note informed consent would be collected formally prior to any research activities
Yes
No
I would be willing to learn more
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24
Are you currently taking any medication like:
MAO-B Inhibitor
, such as Azilect©, Carbex©, Eldepryl©, Emsam©, Xadago©, or Zelapar©) or
Levodopa
(L-Dope), such as Duopa©, Parcopa©, Rytary©, Sinemet©, Stalevo©?
YES
NO
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25
Do you require
assistance
when
walking
?
*
This field is required.
YES
NO
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26
Are you experiencing
hallucinations
?
*
This field is required.
YES
NO
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27
Are you currently participating in a
clinical trial
?
*
This field is required.
YES
NO
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28
Do we have your permission to share the information you provided with our clinical trial partners and/or applicable clinical trial sites?
If yes, please draw your signature inside the box below. We understand it can be difficult to sign with your finger. Don't worry, just do the best you can!
Clear
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