Eligibility Screening Questionnaire
The responses you provide to these questions will not be shared with any individual outside of the research division at ROSM and are used exclusively for research purposes. Your honest and accurate responses are important for our research and may impact your treatment.  You must complete each question to move on to the next stage of screening and participate in the study.
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Email Address *
Which hip is most affected? *
On a scale of 0 - 10 with 0 indicating no pain and 10 indicating most intense pain, please select the pain level in your affected hip. *
no pain
most intense pain
Date of birth *
MM
/
DD
/
YYYY
First Name *
Last Name *
What phone number is best to reach you? *
Do you understand written and spoken English? *
Are you between the ages of 30 and 65? *
Are you pregnant or nursing? *
Is your BMI over 35? *
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Have you been diagnosed with anorexia and/ or chronic insomnia? *
Have you ever been diagnosed with any of the following conditions? *
Required
Have you ever been diagnosed with an auto-immune disease? *
Are you on any anti-coagulant medication (Warfarin, aspirin, cumadin, etc)? *
Have you been prescribed any immuno-suppressive medications? *
Have you had an x-ray of the affected hip taken within the last 6 months? *
Have you ever had surgery to the affected hip? *
If you answered "yes" when asked if you have ever had surgery to the affected hip, please provide the type of surgery performed as well as your surgeon's name.
Have you ever had a regenerative or orthobiologic treatment (Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, etc.) to the affected hip? *
When was the last time you had a corticosteroid injection to the affected hip? *
How many corticosteroid injections have you had to the affected hip? *
Please estimate the number of alcoholic drinks you consumed per week over the past 6 months. *
Which of the following most accurately describes your nicotine use: *
Which of the following most accurately describes your illicit drug use: *
In the last five years, have you been diagnosed with cancer? *
In the last 3 years, have you had chemotherapy, or radiation therapy to the affected hip? *
Have you been diagnosed with an inflammatory arthritic condition (for example: rheumatoid arthritis or lupus)? *
Do you have any disabilities in your lower extremities? *
If you indicated you suffer from a disability in your lower extremities, please specify.
I verify I have answered all questions truthfully and to the best of my abilities. *
Required
I consent to have a ROSM research coordinator contact me by the email and phone number provided. *
Required
Contact Information
Thank you for completing the hip osteoarthritis study screening questionnaire.

If you are deemed eligible to continue the screening process, a ROSM study coordinator will call you at the telephone number you indicated in the next few days to discuss the next steps in the screening process.

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