
Participating cities:

Alabama Birmingham Arizona Phoenix California Santa Monica Florida Merritt Island Illinois Bloomington Minnesota Edina Mississippi Flowood North Carolina Charlotte Ohio New Albany Texas Tyler Virginia Richmond Washington Bellingham

Send site to a friend or family member:

Fill out the form below to send a link to this site to a friend or family member.

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* We do not record any information you submit.

For more information about this research study, please click here to visit our FAQs page or click here to download a brochure.

Pre-Qualifying Questionnaire

To see if you may qualify for this medical research study,
please complete this Pre-Qualifying Questionnaire.

These questions are to be answered by the person who would be enrolled in the research study if they qualify. If you are visiting this website for someone else, please provide this website link to them so that they may complete the questionnaire.

As used in these questions, "you" or "your" refers to the person who would be enrolled in the research study if they qualify.

How did you hear about this research study?

Please enter your home or work zip code. This zip code will be used to locate a study clinic near you. Please provide the zip code that would be most convenient to you.

Enter 5-digit zip code

What is your date of birth?

Month
Day
Year	ex. 1954

Are you male or female?

Male Female

5.	Have you taken or been treated with an investigational drug or device within the last 60 days?
	Yes No Unsure

6.	Do you have pain in your lower back?
	Yes No Unsure

7.	Do you have pain in your legs?
	Yes No Unsure

8.	Have you had surgery on your lower back, such as spinal fusion or total disc replacement?
	Yes No

Privacy Policy: If you pre-qualify for this research study, you will be given a choice to submit your contact information, along with your answers to the questionnaire, to a study clinic conducting this research study. Except as noted above, no personally-identifiable information will be taken from you and your answers will remain confidential. We will not use your information for any purpose other than to screen you for potential participation in this research study. If you provide your or a friend’s/family member’s email address, the email address will not be provided to anyone other than the person to whom the email was sent as specified in this website. The person in charge of privacy for this website is the Privacy Officer, who may be contacted at 6207 Bee Cave Road, Suite 288, Austin, Texas 78746 or privacy@tprausa.com to make any updates to your information or to have your information removed.

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