Alethios - RELIEF - Remote endometriosis treatment study Screening

Welcome to the RELIEF Study: Managing Endometriosis Pain With At-Home Brain Stimulation

This screening survey will take about 2-3 minutes to complete, and will require you to upload evidence of an endometriosis diagnosis.

How Your Responses Are Handled*

Your responses will be kept confidential. All participants will receive an email confirming their eligibility status (eligible or ineligible). Your responses for this study will be stored to determine eligibility for this study only, and will not be used for any other study. If you are ineligible, your response will not be shared with the research team, but will be stored on the Alethios platform until the study is closed to prevent fraud, "gaming" and using multiple responses from the same individual. All responses from ineligible participants will be deleted at the conclusion of the study, If ineligible, you may later choose to share *only* your name and email address with the Alethios platform to be contacted for other studies you may be eligible for in the future. No other response data will be stored. Please consent to the use of your response as explained above. If you do not consent to the use of your response in this way, you may exit this pre-screener, and no data will be stored.

Yes, I consent.

No, I do not consent.

What is your name?*

What is your email?*

What is your age?*

What is your birth date?*

What is your gender?*

Female

Male

Non-binary

Prefer not to disclose

How long have you experienced chronic pelvic pain?*

3-6 months

6-12 months

1-2 years

2-5 years

More than 5 years

Other

On a scale of 0-10, what is your typical level of pelvic pain?*

0 1 2 3 4 5 6 7 8 9 10

No Pain Worst Pain

Are you currently pregnant, planning to become pregnant in the next 12 months or breastfeeding?*

Yes

No

Do you have any neurological conditions like epilepsy or history of seizures?*

Yes

No

Do you have any metal implants or implanted electronic devices?*

Yes

No

Are you currently participating in any other interventional clinical trials?*

An interventional clinical trial is one in which you are asked to receive a particular treatment, or take a particular drug or intervention or supplement.

Yes

No

Do you have access to a smartphone that is no older than 3 years old, and have a reliable internet connection for study activities?*

Yes

No

Are you currently using hormonal contraception?*

Yes - I have been using the same hormonal contraceptive for more than six months

Yes - I have been using the same hormonal contraceptive for less than six months

No

Do you have a history of stroke, brain surgery, tumours or head trauma?*

Yes

No

Do you have an active scalp condition such as dermatitis, eczema or psoriasis?*

Yes

No

Do you have significant scarring, burns or other forms of skin damage on your scalp?*

Yes

No

Do you have schizophrenia or bipolar disorder?*

Yes

No

Have you showed suicidal behaviour?*

Have you one or more suicide attempts, non-suicidal self-injury [NSSI], or other behaviors indicative of intent to harm oneself?

Yes

No

Other

Are you planning to start or change your treatment plan over the next six months?*

Please do not consider the device in this study as part of your treatment plan.

Yes

No

Are you comfortable speaking, reading, and understanding English?*

This study will be conducted entirely in English

Yes

No

Please spend a few minutes reviewing the Participant Information Sheet on the next several pages.

In addition to the landing page you viewed, this document will provide a crucial overview of the study and technology being tested.

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Patient Information Sheet Page 8/10 TODO

Patient Information Sheet Page 9/10 TODO

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After reading the Participant Information Sheet, are you comfortable completing all the trial activities as described?*

If you have questions, please do not complete the screening questionnaire, and email us at support@alethios.com to be put in touch with the research team.

Yes, I understand and agree to participate in all trial activities

No, I do not feel comfortable participating in all trial activities

Have you been diagnosed with endometriosis?*

Yes

No

Unsure

How would you like to submit evidence of your endometriosis diagnosis?*

You will be able to confirm your initial eligibility in this study without immediately providing evidence. Please select the type of evidence you would be able to submit should you be accepted into this study. If you already have this evidence available, on the next question, you may upload up to 5 supporting documents. These will be reviewed by the research team prior to your being approved to join the study.

Screenshot of health portal showing endometriosis diagnosis

Laparoscopic surgery with biopsy-proven endometriosis, OR

Clear evidence of ovarian endometrioma or deep infiltrating endometriosis on ultrasound/MRI

Screenshot. You may request this evidence from your physician in the form of a letter or note. If you already have this evidence in your healthcare provider's portal or app, you may upload a screenshot.

Other

[Optional] Please provide evidence of your endometriosis diagnosis.

In order to participate in this study, you must upload a confirmed diagnosis of endometriosis by a qualified physician, that shows: - Laparoscopic surgery with biopsy-proven endometriosis, OR - Clear evidence of ovarian endometrioma or deep infiltrating endometriosis on ultrasound/MRI - You may request this evidence from your physician in the form of a letter or note. If you already have this evidence in your healthcare provider's portal or app, you may upload a screenshot. Using this upload button below, you may upload up to 5 supporting documents. These will be reviewed by the research team prior to your being approved to join the study.

Drag and drop file or

click here to upload

Upload up to 5 files up to 10 MB each

Mailing Address

Please enter your mailing address on the screens before.

Mailing Address: Street Line 1*

Mailing Address: Street Line 2*

Mailing Address: City*

Mailing Address: State*

Mailing Address: Zip Code*

What is your phone number?*