1.
Are you or a family member living with Crohn’s Disease (CD) or Ulcerative Colitis (UC), commonly referred to as Inflammatory Bowel Disease or IBD?
Which medication are you or your loved one taking to treat the condition?
2.
Have you or someone you care for been diagnosed with Cancer?
What type of Cancer has been diagnosed?
Is the cancer spreading (metastatic) or is there concern it will spread?
Do you have late stage lung cancer?
Have you or a loved one have had a blood test that was EGFR+?
3.
Do you or someone close to you have Psoriasis?
How would you describe the severity of the Psoriasis?
Please tell us what medications have been used in the last year to treat the Psoriasis: (choose all that apply)
4.
Have you or someone you care for been diagnosed with Epilepsy (Epilepsy is a seizure disorder that can affect anyone)?
Do you have/take rescue medication in the event of a seizure?
How do you administer the rescue medication?
Does the person with Epilepsy experience seizure clusters? (Seizure clusters are periods of increased seizure activity, which is having two or more seizures in a 24-hour period.)
5.
Gastroesophageal Reflux Disease (GERD) and Eosinophilic Esophagitis (EOE) are different conditions with similar symptoms; heartburn/regurgitation, abdominal or chest pain and difficulty swallowing. Have you or a loved one been diagnosed with GERD or EOE?
6.
Have you or someone you care for been diagnosed with a sleep disorder characterized by excessive daytime sleepiness and/or sudden attacks of sleep?
Do you struggle with your CPAP machine?
7.
Do you or a loved one suffer from any respiratory conditions that affect your/their breathing?
What are the respiratory conditions? (choose all that apply)
Do you or a loved one treat severe asthma with a prescription medication?
Is the person with Asthma under 18 years old?
8.
Are you or someone you care for diagnosed with Atrial Fibrillation, or AFib?
Which medication are you or your loved one taking to treat the condition?
9.
Do you or someone you care for suffer from age-related Macular Degeneration?
10.
Do you or someone close to you occasionally experience uncontrolled or involuntary movements like facial tics, movements around the mouth or rapid eye blinking? This could be a condition called Tardive Dyskinesia (TD) and can result from prolonged use of certain medications.
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