Phone: 1-833-411-MYSM (1-833-411-6976)
ARE YOU A TRIAL CANDIDATE?
Take the Online Screener

How did you hear about the SM clinical trials?

Internet search engines advertising (e.g., Google, etc.)

Social media

My doctor referred me

Family member referred me

Cogentbio.com website

Press release/News article

Clinicaltrials.gov

Email

A Clinical Trial Site Referred me

Other

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1. What is your relationship to the potential study participant?

Myself

Spouse

Legally authorized representative of adult

Caregiver

Someone else

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2. Please indicate your date of birth.

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3. Please indicate which best describes the potential study participant:

Diagnosed with Systemic Mastocytosis and know the subtype

Diagnosed with Systemic Mastocytosis but do not know the subtype

No diagnosis, but experiencing symptoms associated with Systemic Mastocytosis

Neither a diagnosis nor experiencing symptoms

This is a required question. Please answer and resubmit.

4. The subtype for the potential participant's SM is best described as:

Advanced Systemic Mastocytosis

Nonadvanced Systemic Mastocytosis

Another subtype

Unknown subtype

Not diagnosed

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5. Please indicate which best describes the potential study participant's current physical capacities:

Fully active and capable of all daily living activities without restriction

Some restrictions in physically strenuous activity but can walk and carry out activities such as light housework or office work.

Able to walk and capable of selfcare but unable to carry out any work activities

Capable of only limited selfcare and confined to bed or chair more than 50% of waking hours

Completely disabled, cannot carry on any selfcare and totally confined to bed or chair

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