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Self-Screening Questionnaire

NON-LETTER SELF-REFERRAL

Please answer the questions below if you would like to speak to a member of the research team about taking part in the study. Your answers will be sent to the University of Leeds Clinical Trials Research Unit (CTRU) D-MAPP coordinating team who will pass your details to the research team in your local area (if there is one), or to the research team at either Leeds Teaching Hospitals or Leeds Community Healthcare. Your details will be stored at the CTRU until the research team have been able to speak with you. If you decide not to take part, your information will be deleted.

D-MAPP_PatientInformationSheetAndConsentForm_v2.0_IRAS-330550_15.11.24_clean
Download Patient Information Sheet

Self-Referral Questionnaire

1. Have you read and understood the participant information sheet?

2. Are you over 18?

3. Have you been medically diagnosed by a registered healthcare professional (GP, physiotherapist, Consultant, nurse Specialist, occupational therapist) with any of the following conditions:

  • Hand osteoarthritis
  • Wrist osteoarthritis
  • Thumb osteoarthritis
  • Elbow pain
  • Carpal tunnel syndrome
  • Non-specific arm pain or any combination of the above

4. How would you rate the pain caused by your condition?

5. Is your distal upper limb pain/symptoms due to any of the following conditions:

  • Upper limb fracture (within the last 12 months)
  • Referred pain from the neck/spine
  • Systemic inflammatory conditions or inflammatory arthritis, for example gout, rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, or polymyalgia rheumatica
  • Diabetic peripheral neuropathies or peripheral nerve injuries involving the upper limbs
  • Diagnosis of complex regional pain syndrome
  • Neurological conditions (e.g., stroke, multiple sclerosis)
  • Ulnar nerve entrapment or trigger finger

6. Have you had any condition where you have been required to use oral steroids in the last 12 months?

7. Have you been diagnosed with cancer within the last 3 years or currently receiving treatment for cancer?

8. Are you happy to provide your contact details for the research team?

9. Are you happy for the research team to contact you in relation to this study?

Privacy Notice

The information you enter here is not stored in any form. The form scores points based on internal criteria in order to determine your potential elgibility for the D-MAPP clinical trial. If the score determines that you are potentially eligible, you will be directed to a contact form where you can send your details to the D-MAPP trial team.

The University of Leeds is responsible for what data is collected, what it is used for and making sure it is used correctly and legally (this means they are called the ‘data controller’). You can ask to see the information we have about you, or have it corrected or deleted. You can also ask for us to stop using your information or only use it in specific ways that you allow. If you would like to do any of these things, please contact the research team on: foxtrot@leeds.ac.uk

For more about how data is used at the Leeds Institute of Clinical Trials Research go to https://ctru.leeds.ac.uk/privacy/