Peanut Allergy Clinical Trial

Peanut Allergy Questionnaire

Thank you for your interest in this peanut allergy clinical trial.

To see if you qualify for this trial, please take 2 minutes to complete the questionnaire below. 

Completing this online questionnaire does NOT obligate you to participate in the peanut allergy clinical trial. 

Any candidates younger than 18 years old can only have their information submitted by a parent, relative, caregiver, or legal guardian who is 18 years of age or older, authorized to submit the child’s information, and who will consent on their behalf. Any reference to ‘You’, ‘Your’ or ‘My’ will refer to the minor child in the case where an adult parent, relative, caregiver, or legal guardian is completing the online questionnaire on their behalf.


1. How old are You?

Less than 5 years old

5-11 years old

12-17 years old

18-55 years old

More than 55 years old

2. How much do You weigh (in lbs)? ?

Weight is one of the criteria to judge eligibility. Eligible participants must weigh more than or equal to 44 lbs (20 kg).

More than or equal to 44 lbs (20 kg)

Less than 44 lbs (20 kg)

3. Have You been diagnosed by a medical doctor for a peanut allergy?

Yes

No

4. Have You been diagnosed by a medical doctor for any of the following food allergies?
Select all that apply:

Hazelnut

Milk

Egg

Other

No food allergies

5. Are You taking any of the following types of medications?

Monoclonal antibodies ?

Common types of monoclonal antibodies include:

  • Omalizumab (Xolair®)
  • Dupilumab (Dupixent®)
  • Benralizumab (Fasenra®)
  • Mepolizumab (Nucala®)
  • Reslizumab (Cinquair®)

Immunotherapies for food allergies ?

A common oral immunotherapy for peanut allergy is PALFORZIA®

Not taking any of the above medications

6. Have You been hospitalized for asthma in the last 12 months?

Yes

No / Not Applicable

7. Have You been hospitalized for a peanut allergy?

Yes, in the past 30 days

Yes, in the past 60 days

Yes, in the past 90 days

No hospitalization in the past 90 days

8. Are You currently participating in another clinical study?

Yes

No

9. Do You have any of the following conditions?
Select all that apply:

Heart Disease (e.g., heart attack, heart failure, stroke)

Cancer

Liver or Kidney Disease

History of alcohol or drug abuse

None of the above

10. Are You pregnant or planning on becoming pregnant in the next 12 months?

Yes

No / Not Applicable

11. What is Your zip code?