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1.
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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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2.
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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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3.
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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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4.
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Under-active thyroid (Hypothyroidism) is a common condition mostly affecting women. Symptoms can include unexplained weight gain, cold sensitivity and fatigue. Do you or someone close to you have Hypothyroidism?
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5.
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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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6.
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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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7.
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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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8.
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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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9.
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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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10.
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Have you or has someone you care for been diagnosed with Parkinson’s Disease and is experiencing, or has experienced off-time while medicated?*
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Have you or someone you care for had Parkinson's for 5 or more years?
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