Phase III Clinical Trial for Multiple Sclerosis – Help Advance Science – Once daily Oral Investigational Medication

Trial related medication & care may be provided at no cost for eligible patients. To see if you might qualify for this clinical trial and to be referred to the local trial center in your area, please take a moment to complete the questionnaire below.

There’s No Obligation

Completing the questionnaire does NOT obligate you to participate in the trial. Your answers help determine if you are a candidate for the trial. If you pass the online pre-screener you will be contacted—only if you grant your permission—by a trial representative. Representatives may contact you by telephone, email or text. Completion of this interview is voluntary. You are free to end this interview at any time. Message and data rates may apply.

1) Have you been diagnosed with Multiple Sclerosis (MS)?

Yes

No

This is a required question. Please answer and resubmit.

2) Do you know what type of MS you have been diagnosed with?

Yes, Relapsing MS (RMS)

Relapsing RMS (RRMS)

Your symptoms of MS come and go. You have MS attacks (relapses) that last for days to weeks and usually get better slowly. You may have relapsing-remitting MS or relapsing secondary progressive MS.

Yes, Secondary Progressive MS, Relapsing (R-SPMS)

Secondary Progressive MS, Relapsing (R-SPMS)

Your symptoms are steadily getting worse but you also have periods of attacks (relapses) that come and go.

Yes, Secondary Progressive MS, Non-Relapsing (nrSPMS)

Secondary Progressive MS, Non-Relapsing (nrSPMS)

Your signs/symptoms of MS initially came and went and you were first diagnosed with relapsing-remitting MS but now your MS has been getting steadily worse and you have few if any attacks (relapses).

Yes, Primary-Progressive MS (PPMS)

Primary-Progressive MS (PPMS)

Your initial MS symptoms came on too slowly to be considered an exacerbation. Since then, your symptoms have continued to steadily get worse. You may also have experienced one or more exacerbations after onset, or you may never have had an exacerbation.

No

This is a required question. Please answer and resubmit.

3) Have you taken either Alemtuzumab in the past 4 years or Mitoxantrone in the past 2 years?

Yes

No

This is a required question. Please answer and resubmit.

4) Have you taken either Natalizumab, Ocrelizumab, or Rituximab in the past 6 months?

Yes

No

This is a required question. Please answer and resubmit.

5) Are you taking any blood thinners or antiplatelet medications and if so, do you need to take them on a long term basis?

Examples include warfarin, clopidogrel, heparin, dabigatran, apixaban, edoxaban, rivaroxaban

Yes

No

This is a required question. Please answer and resubmit.

6) Do any of the following apply to you? (Check all that may apply.)

Diagnosed with cancer in past 5 years (excluding some successfully treated skin or cervical cancers)

Hospitalization for any psychiatric condition (e.g. depression, schizophrenia, bipolar) in the past 2 years

You are a woman who is pregnant or planning on becoming pregnant in a few years?

Diagnosed with HIV

Diagnosed with Hepatitis B or C

Receiving dialysis treatment for kidney failure

Diagnosed with Class 3 or Class 4 heart failure

Prior organ or bone marrow transplant

None of these conditions apply

This is a required question. Please answer and resubmit.

7) Are you confined to a wheelchair?

Yes

No

This is a required question. Please answer and resubmit.

8) What is your year of birth (example: 1975)?

This field is required. Please enter a valid birth year. Please answer and resubmit.

9) What is your ZIP/postal code?

This is a required question. Please answer and resubmit.
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