test-post Step 1 of 12 8% How did you first learn about the study? Facebook Internet Search Friend/Family Physician Referral Choose a Location Are you between the ages of 30 – 70?* Yes No Are you currently dealing with sciatica pain or numbness that radiates (shoots) down behind your buttock, thigh, or leg?* Yes No Not Sure Where is your sciatica pain worst?* Mostly in my leg (this could also include the buttock) Mostly in my back Both my leg and my back Does your sciatica pain mostly affect one leg or both?* One leg Both legs Not sure For many people, their sciatica leg pain comes and goes in cycles. If you think about this CURRENT bout of pain you are dealing with, about how long has it lasted?* Less than 1 month 1 month – 6 months 6 months – 1 year More than 1 year Have you ever been diagnosed by a doctor as having a bulging or herniated disc in your lower back?* Yes No Have you ever had surgery on your lower back? (Please note: this would NOT include a previous steroid or nerve block injection)* Yes No Are you willing to consider a single injection in your lower back for your sciatica symptoms?* Yes No Are you currently involved in any litigation regarding your low back/leg pain, or receiving worker’s compensation?* Yes No HiddenDoes the Referral ALMOST Qualify? QualifiedHidden notQualifiedHidden Thank you. You may not have pre-qualified for the study based on one or more of your answers.Thank you. If you are still interested, please enter the information below and your local study site will contact you directly within the next few days. They will tell you more about the study, and answer any questions you might have. By speaking with your local study site, you are not under any obligation to enroll in the study. Also, only your local study site can determine if you fully qualify to join the study. Please note: your contact information will only be shared with your local study site so that they can follow-up with you directly to discuss the study – it is not used for any other purpose.Thank you. If you are still interested, please enter the information below and your local study site will contact you directly within the next few days. They will tell you more about the study, and answer any questions you might have. By speaking with your local study site, you are not under any obligation to enroll in the study. Also, only your local study site can determine if you fully qualify to join the study. By submitting this form you authorize Indegene and its affiliates to communicate with you regarding this study using phone calls, faxes, and text messages, including those sent to a cellular telephone number using an automatic telephone dialing system, prerecorded or automated voice or those sent for a commercial, telemarketing or advertising purpose. You consent to receive such communications and agree to pay for any charges that your cellular, landline, or fax carrier may charge you for such services. Your consent is not a condition of purchasing any property, goods, or services.Name* First Last City Phone*Email HiddenDoes the Referral Not Pre-Qualify?
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