Prescreener for BLOOM Clinical Study Eligibility

*What is the age of the potential participant?

13 to 15 years old

16 to 45 years old

Other

Please select an option.

*What is the sex of the potential participant at birth?

Male

Female

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*Has the potential participant been diagnosed with Fragile X Syndrome (FXS)?

Yes, with genetic confirmation of full mutation (≥200 CGG repeats)

Yes, with genetic confirmation of pre-mutation (<200 CGG repeats)

Yes, but I do not know the genetic confirmation information

Please select an option.

*What is the potential participant's height?

Please enter a valid number.

*What is the potential participant's weight?

Please enter a valid number.

*Is there a consistent caregiver who can attend study visits and complete study-related tasks?

Yes

Please select an option.

*Is the potential participant able to swallow tablets or capsules?

Yes

Please select an option.

Please enter your contact information to discuss potential eligibilty.

*First name

Please enter your First name.

*Last name

Please enter your Last name.

*Email address

Please enter a valid email address.

*Phone number

Please enter a valid phone number.

*ZIP code

Please enter a valid ZIP code.

How did you hear about this study?

Please specify

*Consent

This website is supported by Mirum, a pharmaceutical company, or “sponsor.” Mirum will not have access to your and your loved one’s personal information. The Clinical Research Organization (CRO), “a third party,” that works with Mirum will keep your and your loved one’s personal data confidential. The data will be handled in accordance with applicable law, including applicable privacy law.

By checking this box, I have read, understood and accept the Privacy Policy and I authorize the sponsor of the clinical study and its contracted third parties to process my personal and health information as described.

Please select the checkbox to continue.

Completing this survey does not obligate you to participate in this study.

By submitting your and your loved one’s information, you both agree to receive communications including electronic or text messages from the study representatives about this clinical study. You both may unsubscribe from these electronic and text communications at any time. For more information, please visit our privacy policy.

Is my male loved one eligible?

*What is the age of the potential participant?

*What is the sex of the potential participant at birth?

*Has the potential participant been diagnosed with Fragile X Syndrome (FXS)?

*What is the potential participant's height?

*What is the potential participant's weight?

*Is there a consistent caregiver who can attend study visits and complete study-related tasks?

*Is the potential participant able to swallow tablets or capsules?

Please enter your contact information to discuss potential eligibilty.

*First name

*Last name

*Email address

*Phone number

*ZIP code

How did you hear about this study?

*Consent

Our “at-home” option