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PACER Eligibility Questionnaire

Instructions: Please answer each of the following questions to see if you are preliminarily eligible for the study.

YES NO Not sure
1. Are you over 18 years of age?
2. Do you have polymyositis, dermatomyositis, or necrotizing myositis as confirmed by a rheumatologist, neurologist or dermatologist?
3. Do you live in the United States of America (USA)?
4. Are you willing to answer surveys and perform procedures related to the study once a month for 6 months?
5. Are you willing to wear a physical activity monitor (Fitbit) for 7 days a month for 6 months?
6. Are you willing to have an audio-video conference with a study investigator using your smartphone or computer?
7. Are you willing to sign a release of medical record from your doctor in order to obtain myositis related clinical and laboratory data for this study?
8. Will you have follow up care through a rheumatologist, neurologist or dermatologist for the next 6 months?
9. Are you a pregnant or lactating female?
10. Do you have any travel plans (more than a month) or major surgeries planned within the next 6 months?
Disease Symptoms:
11. Have you ever been told by your physicians that you have the rash of DM which includes (roll over the links below for a visual):
(1) Heliotrope (red/purplish discoloration of the eye lids),
(2) Gottron changes (redness or papules over the knuckles, back of the hand, elbows or knees),
(3) V Neck (red rash on upper chest),
(4) Shaw sign, (red rash over upper back), or
(5) Malar rash (red butterfly rash on the face)
12. Do you have, or ever had, muscle weakness of the upper arms and/or legs? (causing difficulty in raising your hands over your head, lifting a small weight such as a gallon of milk,
climbing stairs or getting in and out of a low chair)?
13. Do you have, or ever had, a muscle biopsy done which was consistent with myositis according to your doctor?
14. Do you have, or ever had, an Electromyography EMG (needle study of your muscles) which was consistent with myositis according to your doctor?
15. Do you have, or ever had, elevated muscle enzyme levels [creatine kinase (CK), aldolase, AST, ALT, LDH] according to your doctor?
16. Do you have, or ever had myositis autoantibodies according to your doctor?
Disease Activity:
17. Was your myositis diagnosed within the past 6 months?
18. Do you think your disease is active or inactive?