Patient Eligibility Form

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Survey Introduction

Living with high blood pressure can be challenging, and research studies like this one help explore new options for patients. Answering a few quick questions will let us know if you may be a good match for this study. This is only an initial step - a participating research site will guide you through the full screening process to confirm eligibility.

(Check Yes, No, or Not Sure for each unless otherwise indicated.)

First name(Required)

Last name(Required)

Email(Required)

Phone Number

1. Have you been diagnosed with high blood pressure (hypertension)?(Required)

Yes

2. Do you take two or more blood pressure medications every day?(Required)

Yes

3. Has your doctor told you that your blood pressure is still not controlled despite medication?(Required)

Yes

Not Sure

4. Are you receiving kidney dialysis treatment?(Required)

Yes

5. Have you had kidney stones in the last 6 months?(Required)

Yes

6.Have you had a heart attack or stroke in the last 6 months?(Required)

Yes

7. Are you currently enrolled in another high blood pressure study?(Required)

Yes

8. Do you have atrial fibrillation?(Required)

Yes

Not Sure

9. What is your home zip code?(Required)

Privacy Notice

Your answers will be used only to see if you may qualify for this study and to connect you with a nearby research site if applicable. The study sponsor may review survey results for planning purposes, but your information will not be sold or shared outside the study. Completing this survey does not guarantee participation.

Privacy & Compliance Policy | Notice of Privacy Practices (HIPAA)

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