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1.
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Have you or someone you care for been diagnosed with Cancer?
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What type of Cancer has been diagnosed?
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Is the cancer spreading (metastatic) or is there concern it will spread?
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Do you have late stage lung cancer?
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Have you or a loved one have had a blood test that was EGFR+?
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2.
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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?
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Which medication are you or your loved one taking to treat the condition?
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3.
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Do you or someone close to you have Psoriasis?
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How would you describe the severity of the Psoriasis?
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Please tell us what medications have been used in the last year to treat the Psoriasis: (choose all that apply)
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4.
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Have you or someone you care for been diagnosed with Epilepsy (Epilepsy is a seizure disorder that can affect anyone)?
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Do you have/take rescue medication in the event of a seizure?
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How do you administer the rescue medication?
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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.)
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5.
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Have you or someone you care for been diagnosed with a sleep disorder characterized by excessive daytime sleepiness and/or sudden attacks of sleep?
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Do you struggle with your CPAP machine?
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6.
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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?
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7.
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Hereditary ATTR amyloidosis (hATTR) is a rare genetic condition that often affects the nervous system, cardiac (heart) system and your involuntary bodily functions. Have you or a loved one spoken to a doctor or had a genetic test to confirm an hATTR diagnosis?
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8.
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Do you or someone you care for suffer from age-related Macular Degeneration?
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9.
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Are you or someone you care for diagnosed with Atrial Fibrillation, or AFib?
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Which medication are you or your loved one taking to treat the condition?
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10.
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Have you or someone in your family been diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP), a rare condition characterized by progressive weakness and reduced senses in the arms and legs?
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