Pre-Screening Questionnaire

Please complete this pre-screening questionnaire to see if you qualify for the IDCT trial.

Note: Your answers to the following questions will only be used to determine if you meet preliminary criteria for the clinical study. If you meet the preliminary criteria, you will have the option to enter personal information if you would like to be contacted by a representative from DiscGenics. Your answers to the questions may be collected in aggregate, but will not be associated with your personal information.

2. If you qualify and choose to participate in the IDCT trial, would you be willing to return to the study site for 8 follow-up visits over a 2-year time period? *
3. Are you between the ages of 18 – 75? *
4. Have you been diagnosed by a physician as having degenerative disc disease (DDD) in your lumbar spine (lower back)? *
5. Have you been experiencing chronic low back pain for longer than six months? *
6. Are you pregnant, or do you plan to become pregnant within the next 2 years? *
7. Has a physician ever diagnosed you with fibromyalgia or rheumatoid arthritis? *
8. Do you have any active or open workers’ compensation claims? *
9. Do you have frequent leg pain that extends below the knee? *
10. Have you ever had surgery on your lower back? *
11. Have you participated in another clinical research study within the past 6 months? *
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